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URINARY 

ANALYSIS AND DIAGNOSIS 



BY MICROSCOPICAL 
AND CHEMICAL EXAMINATION 



LOUIS HEITZMANN, M.D. 



NEW YORK 



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PREFACE 

In adding another to the long list of works on the exami- 
nation of urine, the author has been guided by the fact that 
microscopical examination, and especially microscopical diagno- 
sis, have not received as much attention in the text -books as 
their importance calls for, while chemical analysis has been 
thoroughly treated in a large number of works. Many years 
of experience and teaching have shown him that correct diag- 
nosis by means of microscopical examination of urine can 
frequently be made in cases where chemical analysis is of 
little value . 

The work is divided into three parts : First, Chemical 
Examination ; second, Microscopical Examination ; and third, 
Microscopical Diagnosis. The first part is short, and only the 
simplest and most important tests, which alone can be carried 
out by the busy practitioner, are given, although care has been 
taken to omit none of great importance. This subject has 
been excellently treated by many authors, among whom Tyson, 
Purdy, and vonJaksch may be mentioned, and in many larger 
works, which should be referred to when more complicated 
chemical tests are required. 

In many cases in which the clinical symptoms, although 
pointing to an affection of the genito- urinary tract, are vague, 
and, even with the aid of chemical analysis of the urine, will 
not admit of a positive diagnosis, microscopical examination, 
if carefully conducted, will completely clear up the case. It 
is evident that a mere description of the features found in 
different cases can not be sufficiently clear, but that illustra- 
tions made directly from nature are absolutely essential. In 
the present volume all the illustrations, without exception, 



VI PREFACE 

have been drawn by the author directly from specimens in 
his possession. 

In the third part, devoted to Microscopical Diagnosis, full 
page illustrations have been added to elucidate the text, each 
drawing giving the features found in the case it illustrates. 
As the subject is of the greatest practical value, the author 
hopes that this volume may serve a useful end, and will con- 
sider his labors amply rewarded if he has thereby succeeded 
in simplifying this extremely important branch of Micro- 
scopy. 

LOUIS HEITZMANN 

New York, February, 1899 



CONTENTS 



Page 
Introductory 1 



Pakt First 
CHEMICAL EXAMINATION 

CHAPTER I 
General Physical and Chemical Properties (page 7) 

Normal Urine 7 

Amount of Urine 7 

Consistency and Odor 8 

Constituents of Normal Urine 8 

Changes upon Standing 8 

Color of Urine under Pathological Conditions 9 

Amount of Urine under Pathological Conditions 9 

Determination of Specific Gravity 10 

Determination of Solids 10 

CHAPTER II 

Normal Constituents (page 12) 

Urea 12 

Quantitative Tests 13 

Uric Acid 14 

Remaining Organic Constituents 14 

Chlorides 15 

Sulphates 15 

Phosphates 16 

CHAPTER III 

Albuminous Substances (page 17) 

Albumin 17 

Detection of Albumin in Urine 18 

1. Acetic Acid Test 18 

2. Nitric Acid Test 19 

3. Ferrocyanide of Potassium Test 19 

4. Heller's Test 19 

(vii) 



v jji CONTENTS 

Page 

Quantitative Test for Albumin 20 

Peptone 21 

Globulin 21 

Albuniose 21 

Mucin 21 

Fibrin 22 

CHAPTER IV 

Grape Sugar (page 23) 

Detection of Sugar in Urine 23 

1. Moore-Heller Test 23 

2. Trommer's Test 24 

3. Fehling's Solution 24 

4. Haines' Test 25 

5. Bottger's Test 25 

6. Roberts' Fermentation Test 26 

Quantitative Tests for Sugar 26 

1. Fehling's Test 26 

2. Whitney's Reagent 27 

3. Einhorns' Fermentation Saccharometer 28 

CHAPTER V 

Other Abnormal Constituents (page 30) 

Acetone 30 

Diacetic Acid 30 

Coloring Matters 31 

Bile Pigments 31 

Coloring Matter of Blood 31 

Urobilin 32 

Indican 32 

Fatty Matters • 33 



Part Second 
MICROSCOPICAL EXAMINATION 

CHAPTER VI 

General Considerations (page 37) 

Use of Centrifuge 38 

Mounting of Sediment 39 

Use of Antiseptic Substances 39 

Preservation of Sediment 39 

Magnifying Powers 40 



CONTENTS i x 
CHAPTER VII 

Crystalline and Amorphous Sediments (page 42) 

I. Acids and Salts (page 42) 

Page 

A. Acid Sediments 43 

1. Uric Acid 43 

2. Urate of Sodium 47 

3. Oxalate of Lime 49 

4. Cystine 52 

5. Creatinine 52 

6. Hippuric Acid 53 

7, 8. Leucine and Tyrosine 55 

9. Sulphate of Lime . . . 56 

B. Alkaline Sediments 57 

1. Triple Phosphates 57 

2. Simple Phosphates 59 

3. Urate of Ammonium 60 

4. Carbonate of Lime 62 

5. Phosphate of Magnesium 63 

II. Other Unorganized Sediments (page 64) 

Fat 64 

Cholestearin 65 

Haematoidin 65 

Indigo ; . . ^ 67 

Melanin 68 

Urinary Concretions 68 

CHAPTER VIII 

Blood- Corpuscles and Pus -Corpuscles (page 70) 

I. Blood-Corpuscles (page 70) 

Red Blood- Corpuscles or -Globules 70 

White Blood -Corpuscles or Leucocytes 71 

Fibrin 72 

Blood-Clots 72 

II. Pus-Corpuscles (page 73) 

Constitution 75 

CHAPTER IX 

Epithelia (page 78) 

Epithelia Common to Both Sexes 81 

Epithelia from the Bladder 81 

Epithelia from Pelvis of Kidney 83 

Epithelia from the Ureters 84 

Epithelia from the Uriniferous Tubules of Kidneys 84 



x CONTENTS 

Page 

Epithelia Found in Urine of Male 86 

Epithelia from Urethra 86 

Epithelia from Prostate Gland 86 

Epithelia from Ejaculatory Duets 88 

Sperma 88 

Urethral and Gleet-Threads 89 

Epithelia Found in Urine of Female 91 

Epithelia from Vagina 91 

Smegma 93 

Epithelia from Bartholinian Gland 93 

Epithelia from Cervix Uteri 94 

Epithelia from Mucosa Uteri 94 

CHAPTER X 

Mucus and Connective Tissue (page 96) 

I. Mucus (page 96) 

II. Connective Tissue (page 99) 

1. Ulceration - 100 

2. Suppuration 101 

3. Haemorrhage 101 

4. Traumata 101 

5. Tumors 102 

6. Hypertrophy of Prostate Gland 104 

7, 8. Cirrhosis and Atrophy of Kidney 104 

9. Intense Inflammations 104 

CHAPTER XI 

Tubular Casts (page 105) 

I. True Casts (page 106) 

1. Hyaline Casts 108 

2. Epithelial Casts 110 

3. Blood-Casts 110 

4. Granular Casts 112 

5. Fatty Casts 113 

6. Waxy Casts 114 

7. Mixed Casts 116 

Other Casts 117 

II. False or Pseudo Casts (page 117) 

Urate Casts 117 

Bacterial Casts 119 

Pus-Casts 120 

Fat-Casts 120 

Fibrin-Casts 120 



CONTENTS x i 

CHAPTER XII 
Micro- Organisms and Animal Parasites (page 121) 

I. Micro-Organisms or Fungi (page 121) 

Page 

Non- pathogenic Micro -Organisms 121 

1. Mould-Fungi 121 

2. Yeast-Fungi . 123 

3. Fission-Fungi 124 

Pathogenic Schizouiycetse 126 

Gonococci 126 

Other Coeei 129 

Tubercle Bacilli 130 

Typhoid Bacilli 132 

Bacterium Coli Commune 132 

Actinomyces 133 

II. Animal Parasites or Entozoa (page 134) 

Trichomonas Vaginalis 134 

Eehinocoeci 135 

Distoma Haematobium 136 

Filaria Sanguinis Hominis 138 

Ascaris Lumbrieoides 138 

Other Parasites 139 

CHAPTER XIII 

Extraneous Matters (page 140) 

Cotton-Fibers 140 

Linen-Fibers 141 

Silk-Fibers 141 

Wool-Fibers 141 

Human Hairs 142 

Feather 142 

Scales from Moth 142 

Starch- Globules 142 

Lycopodium 143 

Cellulose 144 

Cork 144 

Oil-Globules and Air-Bubbles 14,5 

Flaws in Glass 145 

Vegetable Matter 146 

Faeces 146 



x ii CONTENTS 



Part Theee 
MICROSCOPICAL URINARY DIAGNOSIS 

Page 

Introductory 153 

CHAPTER XIV 
Diseases of the Kidney and Pelvis (page 155) 

I. Inflammations of the Kidney and Pelvis (page 155) 

Classification 155 

Pathological Changes .' 158 

1. Catarrhal Inflammation 158 

2. Croupous Inflammation 159 

3. Suppurative Inflammation 161 

Irritation of the Kidney 161 

Causes 162 

Catarrhal or Interstitial Nephritis 162 

Causes 163 

Clinical Symptoms 163 

Features Found in Urine 164 

Acute Catarrhal or Interstitial Nephritis 165 

Chronic Catarrhal or Interstitial Nephritis 166 

Subacute Catarrhal Nephritis 169 

Cirrhosis of the Kidney . . , 170 

Catarrhal Pyelitis 172 

Croupous or Parenchymatous Nephritis 172 

Causes 172 

Clinical Symptoms 173 

Features Found in Urine 173 

Acute Croupous or Parenchymatous Nephritis 174 

Subacute Croupous Nephritis 178 

Chronic Croupous Nephritis 180 

Atrophy of the Kidney • 184 

Chronic Croupous Nephritis with Acute Croupous Recurrence . . . 185 

Suppurative Nephritis 187 

Causes 187 

Clinical Symptoms 188 

Features Found in Urine 188 

Suppurative Pyelitis 191 

Tuberculosis of the Kidney 191 

Features Found in Urine 193 

II. Anomalies of Secretion (page 194) 

Causes 194 

Clinical Symptoms 194 



CONTENTS x iii 

Page 

Lithcemia 194 

Haemorrhage from the Pelvis of the Kidney 196 

Pyelitis Calculosa 198 

Oxaluria 199 

Hemoglobinuria 199 

Causes 199 

Features Found in Urine 200 

Chyluria 202 

Features Found in Urine 202 

III. Malignant Tumors of the Kidney (page 204) 

Clinical Symptoms 205 

Appearance of Urine 205 

Sarcoma 205 

Features Found in Urine 205 

Cancer 208 



CHAPTER XV 

Diseases of the Bladder (page 209) 

I. Inflammations of the Bladder (page 209) 

Causes 209 

Clinical Symptoms 211 

Appearance of Urine 211 

Catarrhal Cystitis 212 

Microscopical Features 212 

Chronic Catarrhal Cystitis 214 

Acute Catarrhal Cystitis 212 

Subacute Catarrhal Cystitis 217 

Ulcerative Cystitis 217 

Acute Ulcerative Cystitis 217 

Chronic Ulcerative Cystitis 219 

Suppurative Cystitis 219 

Pericystitis 221 

II. Tumors of the Bladder (page 223) 

Clinical Symptoms 223 

Papilloma 223 

Microscopical Features 223 

Sarcoma 226 

Microscopical Features 226 

Carcinoma 227 

Microscopical Features 227 

III. Parasites in the Bladder (page 230) 



x i v CONTENTS 

CHAPTER XVI 
Diseases of the Sexual Organs (page 231) 

Page 

Urethritis 231 

Acute Urethritis 231 

Chrome Urethritis 231 

Prostatitis 232 

Causes 232 

Clinical Symptoms . . . 233 

Features Found in Urine 233 

Acute Prostatitis 233 

Chronic Prostatitis 236 

Hypertrophy of the Prostate Gland 238 

Tuberculosis , 238 

Tumors 238 

Spermatorrhea ... 239 

Seminal Vesiculitis 239 

Clinical Symptoms 240 

Features Found in Urine 240 

Vaginitis 242 

Features Found in Urine 242 

Catarrhal Vaginitis 242 

Traumatic Vaginitis 246 

Cervicitis and Endometritis . 246 



LIST OF ILLUSTRATIONS 

FIG. PAGE 

1. Crystals of Urea and Nitrate of Urea (X 200) 13 

2. Crystals of Uric Acid, Common Form (X 400) 43 

3. Crystals of Uric Acid, Common Form (X 400) 44 

4. Crystals of Uric Acid, from Over-acid Urine (X 450) 45 

5. Uric Acid Gravel (X 500) 46 

6. Urate of Sodium, Amorphous (X 500) 47 

7. Urate of Sodium, Crystalline (X 500) 48 

8. Urate of Sodium in Transition to Urate of Ammonium (X 500) . . 49 

9. Oxalate of Lime Crystals (X 500) 50 

10. Cystine Crystals (X 500) 51 

11. Creatinine Crystals (X 500) 52 

12. Sediment in the Urine of an Athlete (X 500) 53 

13. Hippuric Acid (X 500) 54 

14. Leucine and Tyrosine (X 500) . 55 

15. Complete Triple Phosphates (X 500) 56 

16. Incomplete Triple Phosphates (X 500) 57 

17. Amorphous Simple Phosphates (X 500) 58 

18. Star-shaped Simple Phosphates (X 500) 59 

19. Urate of Ammonium (X 500) 61 

20. Acid Sediment in Fermentation and in Transition to Alkaline (X 500) 62 

21. Carbonate of Lime (X 500) 63 

22. Fat- Globules and Margaric Acid Needles (X 500) 64 

23. Cholestearin Crystals (X 400) 66 

24. Haematoidin Crystals (X 500) 66 

25. Indigo Crystals (X 500) 67 

26. Blood-Corpuscles (X 500) 70 

27. Fibrin and Blood-Clot (X500) 72 

28. Pus-Corpuscles (X 500) 74 

29. Pus -Corpuscles Showing Different Constitutions (X 500) 76 

30. Epidermal Scales (X 500) 80 

31. Epithelia from the Bladder (X 500) 82 

32. Epithelia from Pelvis of Kidney and Ureter (X 450) 83 

33. Epithelia from Uriniferous Tubules of Kidneys (X 500) 84 

34. Comparative Sizes of Corpuscles and Epithelia (X 500) 85 

35. Epithelia from Urethra, Prostate Gland, and Ejaculatory Ducts (X 500) 87 

36. Sperma as Found in Urine (X 500) 88 

37. Gleet-Threads (X 500) 90 

38. Epithelia from the Vagina (X 500) 92 

39. Smegma from the Clitoris (X 450) 93 

40. Epithelia from Bartholinian Gland, Cervix Uteri, and Mucosa Uteri 

(X 500) 94 

(xv) 



xv i LIST OF ILLUSTRATIONS 

Fig. Page 

41. Mucus -Threads and -Corpuscles (X 500) 97 

42. Mucus -Casts, or Cylindroids (X 500) 98 

43. Connective-Tissue Shreds (X 500) 100 

44. Connective -Tissue Shreds Found in Tumors I X 500) 103 

45. Hyaline Casts (X 500) 108 

46. Epithelial Casts (X 500) 109 

47. Blood Casts (X 500) Ill 

48. Granular Casts (X 500) 112 

49. Fatty Casts (X 500) 114 

50. Waxy Casts (X 500) 115 

51. Mixed Casts (X 500) 116 

52. Casts of Urate of Ammonium and Urate of Sodium (X 500) .... 118 

53. False, or Pseudo Casts (X 500) 119 

54. Oidium Laetis (X 500) 122 

55. Penicillium Glaueum and Aspergilli (X 500) 123 

56. Saceharomycetae (X 500) 124 

57. SchizomyeetEe (X 500) 125 

58. Acute Gonorrhoea (X 700) 127 

59. Chronic Gonorrhoea *X 700) 129 

60. Tuberculosis of the Kidney (X 650) 132 

61. Actinomyces (X 500) 133 

62. Trichomonas Vaginalis (X 500) 134 

63. Portions of Echinoeoecus (X 400) 135 

64. Ova of Distoma Haematobium (X 600) 136 

65. Filaria Sanguinis Hominis (X 600) 137 

66. Ova and Portion of Ascaris Lumbricoides (X 500) 139 

67. Cotton-Fibers i'X 500) 140 

68. Linen-Fibers (X 500) 141 

69. Silk-Fibers (X 500] . . . . 141 

70. Wool-Fibers (X 500) 142 

71. Feather (X 400) 142 

72. Scales from Wings of Moth (X 500) 143 

73. Starch- Globules (X 500) 143 

74. Lyeopodium-Globules(X 500 ) 144 

75. Cellulose (X 500) 144 

76. Cork (X 500) 145 

77. Oil-Globules and Air-Bubbles (X 500) 145 

78. Flaws in the Glass (X 500) 146 

79. Vegetable Matter (X 500) 147 

80. Normal Faeces (X 500) 148 

81. Acute Catarrhal Pyelo -nephritis (Acute Interstitial Nephritis) and 

stitis (X 500) 167 

82. Chronic Catarrhal Pyelo-nephritis ('Chronic Interstitial Nephritis) 

and Cystitis (X 500) 168 

83. Cirrhosis of the Kidney. With Chronic Catarrhal Cystitis (X 500) . . 171 

'•.cute Croupous, or Parenchymatous Nephritis, "With Catarrhal 

Pyelitis and Cystitis (X 500) 175 

•ute Hemorrhagic Croupous, or Parenchymatous Nephritis, With 

Catarrhal Pyelitis and Cystitis (X 500) 177 



LIST OF ILLUSTRATIONS xv ii 

Fig. Page 

86. Subacute Croupous, or Parenchymatous Nephritis, With Catarrhal 

Pyelitis and Cystitis (X 500) 179 

87. Chronic Croupous, or Parenchymatous Nephritis, "With Fatty Degen- 

eration of the Kidney, Accompanying Catarrhal Pyelitis and 

Cystitis (X 500) 181 

88. Chronic Croupous, or Parenchymatous Nephritis, With Fatty and 

Waxy Degeneration of the Kidney, Accompanying Catarrhal 

Pyelitis (X 500) 182 

89. Chronic Croupous, or Parenchymatous Nephritis, With Fatty and 

Waxy Degeneration of the Kidney, and an Acute Haemorrhagic 

Croupous Recurrence, Catarrhal Pyelitis and Cystitis (X 500) . . 186 

90. Chronic Pyo-nepln'osis, or Chronic Suppurative Nephritis, With 

Catarrhal Pyelitis and Cystitis (X 500) 190 

91. Acute Abscess of Pelvis of Kidney, or Acute Suppurative Pyelitis 

(X 500) 192 

92. Lithaemia, With Subacute Catarrhal Pyelitis and Cystitis (X 500) . . 195 

93. Haemorrhage from Pelvis of Kidney, Due to Uric Acid Calculus 

(X 500) 197 

94. Haemoglobinuria, Acute Haemorrhagic Croupous, or Parenchymatous 

Nephritis, W T ith Catarrhal Pyelitis (X 500) 201 

95. Chyluria, Catarrhal Cystitis (X 500) 203 

96. Sarcoma of Kidney, Chronic Catarrhal Pyelitis and Cystitis (X 500) 207 

97. Acute Catarrhal Cystitis (X 500) 213 

98. Chronic Catarrhal Cystitis (X 500) . 215 

99. Acute Ulcerative Cystitis (X 500) 218 

100. Chronic Ulcerative Cystitis (X 500) 220 

101. Pericystitis (X 500) 222 

102. Haemorrhage from the Bladder, Due To Papilloma of Bladder 

(X 500) 225 

103. Villous Cancer of the Bladder (X 500) 229 

104. Acute Abscess of the Prostate Gland (X 500) 235 

105. Chronic Prostatitis (X 500) 237 

106. Spermatocystitis, or Seminal Vesiculitis (X 500) 241 

107. Chronic Catarrhal Vaginitis (X 500) 243 

108. Traumatic Vaginitis (X 500) 245 



URINARY ANALYSIS AND DIAGNOSIS 



INTRODUCTORY 

Urinary analysis, in order to be thorough and of practical 
value, must necessarily be both of a chemical and a microscop- 
ical character. Chemical examination, although of great im- 
portance, can, alone, never lead to a correct diagnosis, as it is 
only through the use of the microscope that the nature of the 
disease in the genito- urinary tract, as well as its exact location, 
can be revealed. Every urine to be examined should, therefore, 
be first subjected to different chemical tests, the extent of which 
will vary with the different cases, and then to a microscopical 
examination. 

As a rule, the simpler chemical tests alone will be required. 
These must be made, first, with a view of determining the 
normal constituents of the urine ; and, second, for the purpose 
of learning of the presence of any abnormal constituent. A 
general knowledge of the normal constituents is, therefore, 
necessary, and we must not lose sight of the fact that these 
may vary to a considerable degree, even in perfect health, 
partly from the diet, and partly by conditions of rest or activ- 
ity. An increased or diminished amount of any ingredient 
does not necessarily mean a pathological condition, although 
when this increase or diminution lasts for a long time a diseased 
condition becomes certain. 

In selecting a specimen for examination, it is undoubtedly 
best to obtain samples of urine passed during the whole twenty- 
four hours, wherever this is possible ; the more so since the 
quantity voided is important in diagnosing different affections. 
When this is not practicable, the most concentrated urine, 
which is usually that first voided in the morning, should be 
obtained, although different pathological ingredients, such as 
albumin, may be absent in the morning and yet present in 

(1) 



2 rEIXABT AXAZTSIS AXD DIAGXOSIS 

varying amount? at other time?, especially after meals: so that. 
if any doubt remains as to the exact condition, two samples, 
passed at different times, must be testec 

Care should be taken that the bottles in which the urine is 
kept are scrupulously clean and well corked, and that the urine 
b- obtained in as fresh a condition as possible. When the 
: twenty-four hours' urine is collected, the bottle should be 
kept in a cool place and the urine poured into it as soon as 
possible after being voided. Even then, secondary changes can 
always be guarded again- 1 :. In cold weather such changes 
will usually not take place for many hours, but in warm weather 
decomposition is apt to set in at the end of a few hours, and 

teria develop in varying numbers. When not absolutely 
necessary, it is not advisable to add any preservative to the 

.e until after the chemical tests have been made. Extra- 
neons subjects can easily find their way into the urine when 
care is not exercised as to cleanliness, and these not infrequently 
lead to confusion in examination. 

When urine is received for examination, it should be set 
iside for at least six hours, that a sediment may 1- depo- 
unless it is preferred to use the centrifuge, when examination 
can proceed at once. In the former case he npper part of the 
urine is used for chemical tests, and the sediment for microscop- 
ical examination ; while in the latter, a small amount is used 
foi the centrifugal apparatus, and chemical examination can at 
conducted with r iie remainder. 

After determining the amount of urine vended in twenty -four 
hours, we must note the color, transparency, and reaction, and 
carefully determine the specific gravity. By the amount of 
urine voided, and it- specific gravity, we can. in many eases. 
n if its chief organic constituent, urea (which forms 
about one -half of all the solid ingredients of urine), is above 
or : d; but if the approximate amount of urea is 

chemical tests must be resorted to. 

The next step should always be to determine the presen 
absence of albumin, as well as its approximate amount, and by 
boiling the urine an increaf sphates at once becomes 

apparent. Whenever the specific gravity is above normal, or 
any clinical symptoms lead to a suspicion of the ores 

at a low specific gravity, tests for sugar must 
be r -mould it be desired to know the approximate 



INTRODUCTORY 3 

amount of chlorides, phosphates, and sulphates present (though 
this is not always necessary), the simpler tests for these salts 
will, as a rule, be all that are required. 

Before resorting to microscopical examination, the nature of 
the sediment, whether it is present in small or large amount, 
its color, and its general character should be noted, and then 
all the elements found under the microscope, as well as their 
comparative number, should be carefully observed. It will 
always be safest to examine a number of drops before coming 
to a conclusion and determining upon the diagnosis. 



Part First 
CHEMICAL EXAMINATION 



Part First 
CHEMICAL EXAMINATION 



Chapter I 

GENERAL PHYSICAL AND CHEMICAL 
PROPERTIES 

Normal urine is a yellowish, transparent liquid, of a peculiar 
odor and, usually, of an acid reaction, though the latter may be 
either neutral or slightly alkaline, according to the influence 
of diet. The average amount passed in twenty-four hours is 
between 50 and 60 ounces, or 1,500 and 1,800 cubic centime- 
ters, and its specific gravity varies from 1.015 to 1.025. 

In determining the exact color and specific gravity of urine, 
it is of great importance to have the entire quantity passed in 
twenty -four hours, since both color and specific gravity may 
vary considerably at different hours. As a rule, the more 
highly colored the urine, the higher is its specific gravity. The 
color may vary from an extremely light yellow to a dark yellow, 
or even a reddish hue. 

The amount of urine voided is greatly influenced by different 
factors. It is greater the more liquid is taken into the body, 
and as the amount of solids, which determines the specific 
gravity, usually remains about the same, it follows that the 
specific gravity will be lower, the greater the quantity voided. 
The amount of the perspiratory excretion, too, has a great 
bearing upon the quantity of the urine, and in cold weather, 
when the perspiration is lessened, the urine increases in 
amount. Different articles of diet, such as tea and coffee, 
undoubtedly stimulate the excretion of urine. Nervous excite- 
ment, anxiety, and hard mental work have the same effect. 
Bodily exercise, though increasing the quantity of excreted salts, 
does not increase the watery constituents of the urine. The 

(7) 



8 URINARY ANALYSIS AND DIAGNOSIS 

specific gravity of urine voided at different hours of the day 
may. therefore, vary to a great degree, sometimes being as low 
as 1.002 or 1.003. and at other times 1.030. without indicating, 
in any manner, a pathological condition. 

Consistency and odor. — Normal urine is of a watery consis- 
tency, and foams if shaken, though the foam soon disappears 
when at rest. It has a peculiar odor, varying in intensity, 
being most pronounced in concentrated urine. If it has become 
alkaline, it acquires a disagreeable ammoniacal odor. After 
ingestion of certain articles of diet, such as asparagus, and 
after taking different medicines, such as oil of turpentine, 
cubebs, or copaiba, it emits a more or less characteristic odor. 

The constituents of normal urine are partly organic and 
partly inorganic. The organic constituents, held in solution, are 
numerous, though many of them are present in extremely 
small amounts, and are unimportant ; the more important are 
urea, uric acid, oxalic acid, hippuric acid, creatinine, lactic 
acid, coloring matters, and a minute amount of grape sugar. 
The coloring matters which may exist in normal urine, though 
all are not necessarily found in every case, are urobilin, uroxan- 
thin. uroerythrin, and uroindican. The inorganic constituents 
are chloride of sodium, phosphate of soda, phosphates of magne- 
sia and lime, sulphates of alkalies, and ammoniacal salts. The 
gaseous constituents are carbonic acid, nitrogen, and oxygen, 
the latter in very small amount only. The total amount of 
solids voided with the urine in twenty -four hours is between 
60 and 70 grammes, or 925 and 1,080 grains ; the organic 
elements being present in the proportion of 25 to 30 in 1.000 
parts, and the inorganic in the proportion of 10 to 15 in 
1.000 parts. 

Changes upon standing. —If normal urine is left at rest for a 
few hours, a cloudy sediment, more or less pronounced, will 
be formed, and is usually more marked in the urine of females. 
This sediment will disappear entirely upon shaking. It consists 
of mucus, with a few flat epithelia from the bladder, and. in 
the urine of females, from the vagina. In addition to these 
features, epidermal scales from the prepuce and nymphse will 
always be found, and at the time of menstruation a large num- 
ber of blood -corpuscles. Spermatozoa may also be present. 

After the urine has remained standing for one or more days, 
bacteria will develop, their number and rapidity of development 



PHYSICAL AND CHEMICAL PROPERTIES 9 

depending 1 upon the temperature. In warm weather they may 
appear in the course of a few hours. In highly acid urine 
conidia and mycelia will not infrequently form, though cocci 
and bacilli may also be found. In alkaline urine fission-fungi, 
— both cocci and bacilli, — are seen in large numbers. When 
amnion iacal decomposition of the urine sets in, the urea is 
gradually transformed into carbonate of ammonium through 
the activity of the micro-organisms. Saccharomycetse, or yeast- 
fungi, may also be present in the urine, and are most common 
in that containing sugar. 

Under pathological conditions the urine may be passed as 
a cloudy liquid of varying consistency. The highest degree of 
viscidity is usually found in chronic cystitis, when the urine, 
being strongly alkaline and decomposing in the bladder, appears 
as a viscid, stringy, muco- purulent mass, with a repulsive 
ammoniacal odor ; it contains a varying number of bacteria 
and a large amount of phosphates. 

The color of the urine will be greatly changed by an increase 
or decrease of the normal coloring matters, or the abnormal 
presence of biliary matter. When the urine is mixed with blood 
it will be more or less dark colored. In febrile conditions it is, 
as a rule, highly acid in reaction, and has a reddish or reddish 
brown color, partly due to an excessive amount of urea and the 
urates, and partly to a red extractive matter known as uroery- 
thrin. The same may be the case in many slight disturbances 
of the system. 

The amount of urine is usually, though not invariably, in- 
creased in diabetes, and its specific gravity is generally high — 
1.030, 1.040, or more. In some cases of diabetes, however, the 
specific gravity may not only be normal, but below normal — 
1.015, or even 1.010 — and still a large amount of sugar may be 
present. The quantity of urine is also considerably increased in 
cirrhosis of the kidney, but here the solid constituents, and with 
them the specific gravity, are greatly decreased. Patients suf- 
fering with cirrhosis constantly void large quantities of pale, 
almost colorless urine, nearly destitute of salts, with a specific 
gravity frequently below 1.010. The amount of urine is de- 
creased in acute inflammations of the kidney, as well as in acute 
inflammatory conditions of the other organs. Any intense bodily 
strain, accompanied by free perspiration, will lessen the amount 
and increase the specific gravity. 



10 UEIXAEY ANALYSIS AND DIAGNOSIS 

Determination of Specific Gravity. — The simplest method of 
testing the specific gravity is by means of the urinometer. which, 
if carefully constructed, will be sufficiently accurate for all prac- 
tical purposes. If tested with plain water, such a urinometer 
will sink to the 1.000 mark at the average temperature of the 
room. The specific gravity of a specimen should only be taken 
after it is cooled ; otherwise errors will result. The glass cyl- 
inder supplied with the instrument should be fluted, so that the 
latter will not cling to the side of the glass. The test is made 
as follows : Fill the cylinder four -fifths full of urine, removing 
the froth, if any is present, with filtering paper. Place the 
urinometer in the urine, being careful not to allow it to come 
in contact with the walls of the vessel. Bring the eye on a 
level with the surface of the urine, and read the corresponding 
division of the urinometer. but not the upper rim of the fluid, 
raised a little by capillary attraction. Touch the stem, causing 
the urinometer to sink slightly in the fluid, and. after it has 
come to rest, read again. 

If the amount of urine is small, dilute the specimen with 
one, two, or even three volumes of water ; test as before 
directed, and multiply the number of the division -mark by the 
number of volumes used in the process of dilution. For exam- 
ple, if two volumes of water have been added to one volume of 
urine, thus making three volumes in all. and the urinometer 
stands at 1.006, the real specific gravity of the original urine 
is 1.018. The solid materials upon which the specific gravity 
depends, which were dissolved in one volume, are. after dilu- 
tion, dissolved in three volumes, and the specific gravity is 
therefore only one -third of the original. 

Determination of Solids. — If we wish to determine the amount 
of solids present in the urine voided during twenty -four hours, 
we must know the exact quantity passed during this time, as well 
as its specific gravity. The approximate amount of the solids 
can be obtained by multiplying the last two figures of the 
specific gravity by the coefficient of Haeser. which is 2.33, and 
it will give the number of grammes of solid matter in 1,000 cubic 
centimeters of urine. 

For example, suppose we have 1.500 cubic centimeters passed 
in twenty-four hours, of a specific gravity of 1.020. To estimate 
the amount of solids in 1,000 cubic centimeters, or 32 ounces, we 
multiply the last two figures, 20, by the coefficient, 2.33, which 



PHYSICAL AND CHEMICAL PROPERTIES 11 

gives us the product, 46.60, the amount of solids, in grammes, in 
1,000 cubic centimeters ; this is equal to 720 grains. The quan- 
tity present being 1,500 cubic centimeters, or 48 ounces, the 
amount of the solids will be 69.90 grammes, or 1,080 grains. 
Valuable conclusions as to the amount of solids may thus be 
obtained from the specific gravity in a very short time. In 
diabetes, for instance, the quantity of urine voided being large 
and of a high specific gravity, the amount of solids is consid- 
erably increased ; in inflammations of the kidney, on the other 
hand, where the quantity of urine is decreased and the specific 
gravity is low, the amount of solids is diminished. Since urea 
composes nearly one -half of the solid constituents, it can easily 
be seen that in the latter case it has not been excreted in 
sufficient quantity. 



Chapter II 
NORMAL CONSTITUENTS 

Urea. — Urea is the chief organic constituent of urine, and 
its most important nitrogenous product. The greater portion of 
nitrogen taken into the system with the food is excreted by the 
kidney in the form of urea. The quantity excreted varies 
greatly under different physiological conditions, but averages 
between 25 and 40 grammes, or 375 and 600 grains, in twenty- 
four hours, it being about one -half of the solid ingredients 
voided. The specific gravity of the urine alone will, therefore, 
give an approximate idea of the amount of urea therein, pro- 
vided no sugar is present and the amount of chlorides is nor- 
mal. A specimen of normal urine with a specific gravity of 
about 1.020, and voided in a quantity of about fifty ounces, 
will cod tain approximately two or two and one -half per cent 
of urea. 

Normally the amount of urea excreted varies greatly with the 
diet, being most abundant after eating nitrogenous food. It is 
also increased after muscular exercise and mental activity. 
Pathologically, it is increased during fevers and in diabetes, 
in the latter condition sometimes to an enormous extent. It 
is decreased in diseases of the liver — the liver being the chief 
seat of the formation of urea, — in diseases of the kidney, and 
in chronic affections impairing the vitality of the patient. 

Urea is always held in solution, and can never be found under 
the microscope without chemical means. It crystallizes in the 
form of colorless quadrilateral plates, or prisms, and in needles 
of varying sizes. It can easily be detected as nitrate of urea by 
placing a few drops of urine upon a glass slide, adding a drop 
of nitric acid, warming the slide carefully, and placing it aside 
to crystallize. Under the microscope, more or less regular 
rhombic or hexagonal plates, either single or overlapping each 
other, will now be found. These plates have a little color, am 
are perfectly characteristic. (See Fig. 1.) 

(12) 



NORMAL CONSTITUENTS 



13 



Quantitative tests. — The quantitative tests for determining 
the exact amount of urea present in the urine are numerous, 
but more or less complicated. The simplest is the hypobromite 
method, the principle of which depends upon the fact that, when 




Fig. 1. Crystals of Urea and Nitrate op Urea (X 200). 

urea in solution comes in contact with a sodium -hypobromite 
solution, nitrogen is set free as a result of the total decomposi- 
tion of the urea. The quickest way of carrying out this method 
is by means of Doremus' ureometer. The hypobromite solution 
necessary for this test does not keep well, and it is, therefore, 
best to keep the bromine and the caustic sodium solution sep- 



14 URINARY ANALYSIS AND DIAGNOSIS 

arate. Have on hand a solution of sodinm hydrate— 100 
grammes of caustic soda to 250 cubic centimeters of water (3 
ounces to 8)— and the bromine in separate bottles. To prepare 
the solution, take ten parts of the sodium hydrate solution and 
one part of bromine, and dilute with equal parts of water ; 
the solution is then ready for use. 

Doremus' apparatus consists of a bulb and graduated tube, 
and a small curved nipple -pipette to hold one cubic centimeter 
of urine. The bulb of the ureometer is filled with the hypo- 
bromite solution, and by inclining the tube, the loug arm is 
filled to the bend at the bulb. By means of the nipple -pipette 
one cubic centimeter of urine is drawn up, the pipette passed 
through the bulb of the ureometer as far as it will go in the 
bend, and the nipple compressed gently and steadily. The 
urine will rise through the [hypobromite and the urea instantly 
decomposes, giving off nitrogen gas. The decomposition of 
urea is complete in ten or fifteen minutes, and the graduation on 
the tube will indicate the quantity of urea in one cubic centi- 
meter of urine. To obtain the percentage, multiply the num- 
ber of divisions on the tube by 100. 

Uric Acid. — Of the other normal organic constituents in the 
urine, the most important are uric acid and the urates. Uric 
acid is normally voided in small amount only, and is in direct 
proportion to the urea, being about 1 to 45 ; the average quan- 
tity voided in twenty -four hours is from 7 to 12 grains (0.4 to 
0.8 grammes). 

The simplest method of determining the presence of this acid 
is by microscopical examination. Occasionally, however, it may 
become necessary to employ a chemical test for its recognition, and 
the quickest is the murexide test. A small portion of the sedi- 
ment, or the residue after evaporation, is placed on a porcelain 
dish, a few drops of a strong solution of nitric acid are added, 
and the solution carefully warmed. When dry, a few drops of 
liquor ammonia? are added, and a beautiful purple color will at 
once appear, which soon spreads over the dish, and will change 
into violet upon the addition of caustic potash. 

For the remaining organic constituents, which, so long as they 
are held in solution, have no practical significance, chemical tests 
are not necessary. Oxalic acid never occurs in the urine in a 
free state, but always in combination with lime, and, as such, is 
seen under the microscope. Creatinine and hippuric acid will 




NORMAL CONSTITUENTS 15 

always be found under the microscope when present in abnor- 
mally large amounts. Coloring matters, found in small quan- 
tities in normal urine, are increased in pathological conditions, 
and will be considered later on. 

The chief inorganic constituents of the urine are the chlo- 
rides, sulphates, and phosphates. 

Chlorides. — The chlorides present in the urine are chloride of 
sodium (the most abundant) and small quantities of chloride of 
potassium and ammonium. The amount of the chlorides voided 
varies considerably with the diet, being most abundant when a 
large amount of salty food is ingested. The average quantity 
voided is between 10 and 16 grammes (2% to 4 drachms) in 
twenty -four hours. The excretion of chlorides is diminished in 
all febrile conditions, especially when attended by serous exuda- 
tions. In pueumonia they are greatly decreased, and may be 
entirely absent in severe cases ; they may also be diminished in 
cases of chronic nephritis. 

The chlorides may be detected by treating the urine with 
nitric acid and adding a solution of nitrate of silver ; a cheesy 
precipitate, soluble by the addition of ammonium, shows the 
presence of chlorides. A test of the approximate amount of 
chlorides present may be made with this method as follows : 
To a small amount of urine in a test-tube add a few drops of 
nitric acid, and to this one or two drops of a nitrate of silver 
solution, one part to eight. If a white, flaky precipitate is 
formed, which quickly sinks to the bottom of the test-tube with- 
out diffusing through the urine, the chlorides are present in 
normal amount (from one -half to one per cent). If a simple 
cloudiness appears, readily diffusing through the urine without 
the appearance of flakes, the chlorides are diminished to one- 
tenth per cent ; and if no precipitate whatever is formed, they 
are entirely absent. 

Sulphates. — The sulphates occurring in the urine are mostly 
those of sodium and potassium, the former predominating. The 
quantity excreted by the kidneys varies from 2 to 3 grammes 
(30 to 45 grains) in twenty -four hours. An increased excretion 
takes place after a meat diet and as a result of active exercise ; 
this is also the case in acute fevers with an increased excretion 
of urea. Sulphates are diminished after a vegetable diet. 

They may be detected by adding to a given quantity of urine 
in a test-tube one -third as much of an acidulated solution of 



16 UBINABY ANALYSIS AND DIAGNOSIS 

barium chloride (2 parts to 8 of water, with one -half part of 
hydrochloric acid). An opaque, milky cloudiness will appear 
when the amount of the sulphates is normal. If the opacity is 
intense, and the mixture has the appearance of cream, the 
sulphates are increased ; but if there is only a slight cloudiness, 
they are diminished. 

Phosphates. — The phosphates present in the urine consist 
partly of earthy and partly of alkaline phosphates. The earthy 
phosphates are insoluble in water, and are held in solution in 
acid urine, but are precipitated in alkaline urine. The alkaline 
phosphates are soluble in water, and are not precipitated from 
solution by alkalies. The earthy phosphates are phosphates of 
calcium and magnesium, and the amount excreted in the urine is 
from 1 to 1% grammes (15 to 23 grains) in twenty -four hours. 
If the acid -magnesium phosphate be acted upon by ammonium, 
the ammonio- magnesium phosphate — so-called triple phosphate — 
is formed. The alkaline phosphates are the acid phosphate of 
sodium and ,phosphate of potassium ; their amount varies from 
2 to 3 grammes (30 to 45 grains) in twenty -four hours. 

The phosphates vary considerably in amount with the diet, 
being more abundant after taking vegetables and alkaline waters. 
The earthy phosphates are increased in diseases of the bone, 
as osteomalacia and rhachitis, and diseases of the nerve-centers, 
but are diminished in pronounced diseases of the kidneys. 

The earthy phosphates may be detected by rendering the urine 
strongly alkaline with caustic potash and gently heating, which 
causes them to precipitate. To detect the alkaline phosphates, 
remove the earthy phosphates by precipitation, and add to a 
given quantity of urine one -third the quantity of maguesian 
fluid (1 part each of magnesium sulphate and ammonium chloride, 
8 parts of water, and 1 part of pure liquor ammoniae) . All the 
phosphates are precipitated in the form of a snow-white deposit. 
If the entire fluid presents a milk -like, cloudy appearance, the 
alkaline phosphates are present in normal amount ; if it is 
denser and more cream -like, there is an increase, but if the fluid 
is only slightly cloudy, the phosphates are diminished. 



Chaptee III 

ALBipiNOUS SUBSTANCES 

Albumin. — Of all the chemical tests, one of the most im- 
portant is undoubtedly that for albumin, by which term serum- 
albumin is always meant. The presence of albumin does not 
necessarily signify the presence of a renal trouble, and, if found 
in small amount only, may be due to a variety of causes. Even 
a comparatively large amount may exist without any kidney- lesion 
whatever, and it is a grave mistake to conclude that a nephritis 
must exist because albumin has been found. It is undoubtedly 
true that in the larger number of cases in which albumin is 
present a nephritis exists, yet in such cases a microscopical 
examination must always be made, and then only if pus -cor- 
puscles and kidney -epithelia, with or without casts, are found 
can a diagnosis of a nephritis be made. 

On the other hand, a nephritis may exist and yet albumin be 
found in such minute quantities as to occasionally escape detec- 
tion altogether. This is sometimes the case in cirrhosis of the 
kidney, where a large amount of albumin is rarely seen, and 
it may be entirely absent for a few hours. In such cases the 
urine of the entire twenty -four hours should be tested before 
concluding as to the presence of albumin. 

In all cases where pus -corpuscles in moderate numbers are 
found in the urine, albumin will always be detected, if careful 
tests are made, though there maybe no more than a faint trace. 
It can thus easily be seen that in such widely different lesions as 
pyelitis, cystitis, prostatitis, urethritis, and vaginitis, it might 
be present in the urine, and a microscopical examination will be 
necessary to determine its origin. In haemorrhage from any 
portion of the genito- urinary tract, a considerable amount of 
albumin is usually found. The rare cases of chylous urine, in 
which the kidney may be perfectly intact, are always associated 
with the presence of a large- amount of albumin. 

Disturbances of circulation, due to a variety of different 
B (17) 



28 URINARY ANALYSIS AND DIAGNOSIS 

causes, may bring about the presence of albumin without any 
structural changes in the kidney or any pus -corpuscles in the 
urine. Such cases are often roughly termed functional albu- 
minurias. It is not always easy to trace the cause of such 
albuminurias, though they may be due to nothing but prolonged 
muscular exei lesions of the nervous system, or to organic 

heart -lesions, etc. If long continued, these eases will sooner 
or later cause inflammations of the kidney. Albuminuria of 
pregnancy, due ro the pressure of the pregnant uterus, is 
very common, and in many of these cases an organic lesion of 
the kidney will develop. 

Changes in the composition of the blood with a broken down 
constitution, as seen in anaemia, tuberculosis, malaria, leucaemia, 
pyaemia, etc.. will cause the appearance of albumin, and this may 
also be the case in any other febrile condition. 

Detection of Albumin in Urine. — 1. Acetic Acid Test.— 
The tests for albumin are quite numerous, but one of the most 
reliable is the following : Fill an ordinary test-tube about one- 
fourth or one-third full of orine. and boil thoroughly j then add 
two or three drops of a solution composed of equal parts of 
glacial acetic acid and water. I: lin is present, the urine 

becomes cloudy, the cloudiness being the more pronounced the 
larger the amount of albumin. 

The unboiled urine, as brought for examination, is either 
transparent or cloudy. When the urine is boiled, the results may 
be the following : 

a. The urine is transparent, and upon boiling, remains 
unchanged. This indicates normal urine. 

b. The urine is transparent, but after boiling becomes 
cloudy. By adding a few drops of acetic acid, it clears up 
entirely. This shows the presence of an increased amount of 
phosphates. If effervescence occurs upon the addition of the 
acid, either carbonate of lime or carbonate of ammonium I 
latter being always held in solution, and never precipitated so as 
to be found under the microscope) is present. 

e. The urine is transparent, but after boiling becomes cloudy. 
and the cloudiness remains or becomes more pronounced upon 
the addition of the acid. This indicates the presence of albu- 
min, which, in larger quantities, will be thrown down in flakes: 
when very abundant, the urine may be converted into a jelly- 
like mass. The acetic acid test will show the presence of the 



ALBUMINOUS SUBSTANCES 19 

smallest traces of albumin, though these may escape detection if 
not carefully observed. The best plan in such cases is to take 
a second test-tube and pour into it unboiled urine ; then com- 
pare the two test-tubes in strong* light. When this is done, the 
faintest trace of albumin can be detected by the slight cloudiness 
in the test-tube containing the boiled urine. 

d. The urine is cloudy, but upon boiling clears up entirely 
and remains clear upon the addition of the acid. This indicates 
an excess of urates, especially urate of sodium. 

e. The urine is cloudy, the cloudiness becoming more pro- 
nounced upon boiling and the addition of the acid. This shows 
an excess of urates, in addition to the presence of albumin. 

•/. The urine is cloudy, and remains unchanged by boiling 
and by the addition of acetic acid. This proves the presence of 
micro-organisms, such as micrococci and bacilli. 

2. Nitric Acid Test. — A common test for albumin is the 
nitric acid test, the urine being boiled, and a few drops of nitric 
acid added. This test is not as reliable as the preceding, since 
if a small amount only of albumin be present and the acid 
added be in excess, the albumin may become redissolved. On 
the other hand, if the amount of acid added is small and the 
phosphates are present in excess, a part only of the basic phos- 
phates will be acidified and a soluble albuminate will be formed, 
which remains in solution. 

3. Ferrocyanide of Potassium Test. — Another good test 
is the following : Fill a test-tube with clear urine, filtering it 
first if not clear ; add 5 to 10 drops of acetic acid and a 
few drops of a 10 per cent ferrocyanide of potassium solution. 
If albumin is present, a cloudiness will at once appear, and 
become more pronounced upon shaking. 

4. Heller's Test. — Still another frequently employed test 
is Heller's. It is used as follows : Upon a quantity of pure 
nitric acid in a small test-tube allow an equal amount of clear 
urine to trickle from a pipette down the side of the inclined 
tube, so that the urine overlies the acid. If albumin is present, 
a sharp white zone will appear at the point of contact between 
the acid and the urine, varying in thickness according to the 
amount of albumin present. If only a trace of albumin be 
present, fifteen to thirty minutes may elapse before the zone 
becomes visible. 

Although a large number of other tests are occasionally used, 



20 URINARY ANALYSIS AND DIAGNOSIS 

these few will be all that are necessary for practical purposes. 
Perhaps the most reliable is the first one given— the heat and 
acetic acid test. If doubt remains as to the presence of albu- 
min, any of the other tests given will clear up the question. 

Quantitative Test for Albumin. — It is of the utmost impor- 
tance to have an approximate idea of the quantity of albumin 
present in any given case, and too many errors are constantly 
made in this respect. It is by no means rare to hear of a urine 
containing 25, 40, or even 50 per cent of albumin. What is 
thereby meant is, of course, per volume ; yet such statements 
are absolutely misleading. As a matter of fact, one -tenth of 
1 per cent is a moderate amount of albumin, one -twenty -fifth 
of 1 per cent being a small amount; one -half of 1 per cent is 
a large amount, and it is only in comparatively rare cases that 1 
per cent or more is present ; more than 3 or 4 per cent 
is probably never found. 

The simplest method of estimating the approximate amount 
of albumin is by means of Esbach's albuminometer. This in- 
strument consists of a graduated glass tube, which is filled with 
urine to the letter U marked upon the tube, and with the test- 
solution to the letter R. The latter consists of one part of picric 
acid to coagulate the albumin, two parts of citric acid to hold 
the phosphates in solution, and distilled water to make one 
hundred parts. The tube is now closed with the rubber stopper 
supplied with it, and the contents thoroughly mixed. It is then 
set aside for twenty -four hours to allow the precipitate to settle 
thoroughly, and the amount of the precipitate carefully noted. 
The tube contains seven main lines of division, each one of 
which signifies one gramme of albumin in 1,000 grammes,— that 
is, one -tenth of one per cent. It will be seen that the instru- 
ment is only graduated for seven -tenths of 1 per cent, and this 
is sufficient for most cases. In those rare cases in which more 
than that amount of albumin is present, the urine must be di- 
luted with one, two, or even three parts of water before testing 
It must always be borne in mind that this method can never be 
absolutely accurate, since picric acid will also precipitate urates, 
peptone, and vegetable alkaloids ; but it undoubtedly gives an 
approximate idea, which is all that is required in most cases. 

Besides serum -albumin, the urine sometimes contains a number 
of similar but less important substances, among which may be 
mentioned peptone, globulin, albumose, mucin, and fibrin. 



ALBUMINOUS SUBSTANCES 21 

Peptone.— Peptone is never present in normal urine, but is 
frequently seen in many different conditions in which there is a 
formation of pus and disintegration of pus -corpuscles somewhere 
in the body. It has been found in the following conditions : 
Croupous pneumonia, pulmonary tuberculosis, gangrene of the 
lungs, empyema, cancer (especially of the gastro - intestinal tract 
and the liver), different abscesses, acute yellow atrophy of the 
liver, phosphorus poisoning, typhoid fever, typhus fever, variola, 
scarlet fever, erysipelas, acute arthritis, etc. It has, however, 
also been found in physiological conditions, such as the involution 
of the pregnant uterus, so that its presence does not necessarily 
signify a diseased condition. 

Peptone is easily soluble in water, does not coagulate by heat- 
ing, and does not precipitate by the addition of most of the 
reagents used for the detection of albumin, such as nitric acid, 
acetic acid, and ferrocyanide of potassium. 

It may be detected by the following method : To urine which 
has been slightly acidified by acetic acid, add a solution of 
sulphate of ammonium to saturation, and filter out any pre- 
cipitate having formed, which may consist of albumin, globulin, 
or albumose. If potassio- mercuric iodide or picric acid is now 
added, and a precipitate occurs, this will be peptone. 

Globulin. — Globulin is almost always associated with serum- 
albumin, and its clinical significance is nearly identical with the 
latter. It can be detected by the method of Pohl in the following 
manner : Render the urine slightly alkaline by the addition of 
ammonium hydrate, and filter after standing one or two hours ; 
then add an equal volume of a saturated solution of ammonium 
sulphate. If globulin is present, a precipitate forms. 

Albumose. — Albumose is an intermediate product in the con- 
version of albumin into peptone. It has been found in the 
urine in a number of different conditions, such as osteomalacia, 
ulcerations of the intestines, and multiple sarcomata. Its clinical 
significance is not yet positively known. It is not precipitated by 
heat, but if the urine be made strongly acid with acetic acid, 
and a concentrated solution of table salt be added, it becomes 
precipitated. If the cloudy fluid be now heated, it becomes 
transparent, but turbid again upon cooling, and if more table 
salt be added, it remains precipitated in spite of heating. 

Mucin. — Mucin is present in small amount in every normal 
urine, being more abundant in the urine of females. It is con- 



oo URINARY ANALYSIS AND DIAGNOSIS 

siderably increased in quantity in catarrhal inflammations of the 
gen ito -urinary organs, more especially those of the bladder, the 
prostate gland, and the urethra. When present in large amonnt, 
the urine will appear cloudy soon after it is voided, and it may form 
a ropy, jelly-like mass, which sinks to the bottom of the vessel. 
To detect its presence in urine, dilute with equal parts of water 
and add an excess of acetic acid. If mucin is present, a more or 
less pronounced precipitate forms. To detect it in urine con- 
taining albumin, precipitate the albumin by boiling, and test 
again with acetic acid. Even small amounts can be detected 
with the microscope. 

Fibrin. — Fibrin is fonnd in the urine in greater or less amount 
in hematurias, due to various causes, and is also seen in chylous 
urine. In tumors of the bladder, such as papilloma and cancer, 
where haemorrhages often take place, it is of frequent occurrence. 
It is usually present in the form of coagula when the urine is 
voided, or may be precipitated upon standing. Fibrin is in- 
soluble in water and in salt solutions, as well as in weak acids 
and alkalies. The latter cause it to become gelatinous upon 
cooling, becoming soluble again after prolonged boiling. The 
solutions give the general reactions of albumin. It is, however, 
much easier to detect its presence by the microscope. 



Chapter IV 

GRAPE-SUGAR 

There can be little doubt that the urine may contain small 
amounts of sugar under normal conditions, but the amount 
present in such a physiological glycosuria is so minute that a 
positive reaction will never be obtained with the general methods 
of detecting grape-sugar (dextrose). 

Pathological glycosuria may appear in the urine as a tempo- 
rary condition in the course of a number of diseases, such as 
Asiatic cholera, intermittent fever, cerebro - spinal meningitis, 
diseases of the heart, lungs, liver, and brain, especially those 
involving the fourth ventricle, and in gout. It may, further- 
more, be present in poisoning with certain substances, such as 
morphine and carbonic oxide. 

Whenever sugar is persistently present in appreciable quantity, 
we always have to deal with diabetes mellitus. If a large 
amount of straw -yellow colored urine of a high specific gravity 
is voided, suspicion must at once be directed toward this dis- 
ease, and the urine tested for sugar, even if no other symptoms 
of the affection are as yet present. 

Detection of Sugar in Urine. — The tests for sugar are 
numerous, and in mild cases it may be necessary to resort to 
two or even three different tests before we are positively able to 
determine the presence of sugar. 

1. Moore -Heller Test. — Perhaps the simplest is the 
Moore -Heller test. Although by no means absolutely reliable, 
it is in many cases sufficient to determine the approximate 
amount of sugar. The method is the following : Pour into a 
test-tube two parts of urine and one part of a 10 per cent 
caustic potash solution ; boil the upper portion for two or three 
minutes. Phosphates, if precipitated in large amount, must be 
filtered off. When sugar is present, a change of color will take 
place after boiling, which can be approximately estimated as 
follows : One per cent or less of sugar gives a canary -yellow 

(23) 



24 



URINARY ANALYSIS AND DIAGNOSIS 



color, the color being somewhat more intense than that of the 
original unmixed urine ; between 1 and 2 per cent gives a 
wine -yellow color; between 2 and 3 per cent a sherry 
color ; between 3 and 4 per cent a rnm color, and above 
4 per cent a dark brown or even black color. By the addition 
of a few drops of nitric acid, the liquid loses its dark color, and 
gives out an odor similar to molasses. 

This test is only a tolerably reliable one, but in many cases 
will answer the purpose. The addition of caustic potash to cold 
urine may produce a dark color, which is due to the presence of 
coloring matters of the bile. The white flocculent precipitate, 
which is almost invariably seen with this test, is parti y due to 
the phosphates which caustic potash may precipitate in cold 
urine, and partly to mucine. 

2. Trommer's Test. — To four parts of urine in a test-tube 
add one part of caustic potash or soda, adding, drop by drop, a 
10 per cent solution of sulphate of copper, and shake until the 
mixture shows a blue color. Heat the upper part of the mixture, 
and if sugar is present a precipitate of yellow cuprous hydroxide 
will result, which at first shows plainly in the bluish liquid, but 
gradually spreads over the entire fluid, and a red sediment of 
cuprous oxide is formed. 

If this reaction takes place upon heating, a similar mixture 
may be made and set aside for a number of hours without heat- 
ing ; if sugar is present in rather large quantities, a similar 
precipitate will form. Should the reaction by heating be at all 
doubtful, the second test must always be made, since many of 
the other organic substances, which reduce the salts of copper, 
do so only after heating and boiling. 

This test is open to a number of objections. Albumin, if 
present in large quantities, must first be removed, since it in- 
terferes with the reduction of the cupric oxide. A number of 
substances are, furthermore, found in urine which have the 
property of reducing oxide of copper in an alkaline solution, 
among which may be mentioned uric acid, creatinine, hippuric 
acid, and mucine. Again, a small amount of sugar may be 
present in urine, and fail to reduce the oxide in the presence of 
other substances, such as urate of ammonium, chloride of am- 
monium, and other ammoniacal compounds. 

3. Fehling's Solution.— This solution is prepared in the 
following manner : First dissolve 34.639 grammes of pure 



GRAPE-SUGAR 25 

crystallized sulphate of copper in a sufficient quantity of water 
under gentle heat, and dilute with water to 500 cubic centime- 
ters. Next dissolve 173 grammes of chemically pure crystallized 
neutral sodium tartrate and 100 cubic centimeters of caustic soda 
solution, of a specific gravity of 1.12, in sufficient water to make 
500 cubic centimeters. It is best to keep these two solutions 
separate, and mix equal volumes before using. Ten cubic centi- 
meters of this solution will be reduced by 0.05 grammes of 
sugar. 

The solution may be used by pouring a small quantity into 
a test-tube and diluting it with two or three times the amount 
of water. The mixture should be boiled for a few seconds. If 
it remains clear after boiling, which will usually be the case 
when the two solutions are kept separate and are not too old, 
add the urine to be tested drop by drop, at the same time con- 
tinuing the boiling. If sugar be present in any quantity, the 
first few drops will usually cause a yellow precipitate ; if the 
addition of urine is continued, a yellowish red sediment will soon 
fall to the bottom of the test-tube. Should no such precipitate 
occur, the addition of urine may be continued until an equal 
volume of urine has been added ; if then no yellow precipitate 
appears upon boiling, the urine is free from sugar. 

4. Haines' Test. — Take 30 grains of pure sulphate of cop- 
per and one -half ounce of distilled water ; make a perfect 
solution, and add one -half ounce of pure glycerin ; mix 
thoroughly, then add five ounces of liquor potassae. The so- 
lution keeps indefinitely if well prepared. 

In testing with this solution, pour about one drachm into a 
test-tube and boil it gently. Next add 6 to 8 drops of the urine 
and again boil. If sugar be present, a copious yellow or yel- 
lowish red precipitate is formed. If no such precipitate appears, 
no sugar is present. 

5. Bottger's Test. — Pour one part of urine into a test-tube 
and add an equal quantity of a concentrated solution of car- 
bonate of soda, or caustic potash, and a small quantity of sub- 
nitrate of bismuth. Boil for a short time. If sugar is present, 
it reduces the bismuth salts to the black suboxide of bismuth, 
which will be deposited on the sides of the test-tube. If the 
quantity of sugar is small, the bismuth will assume a grayish 
color. Albumin, if present in large quantities, must first be 
eliminated by boiling and filtration. 



26 UBINABT ANALYSIS AND DIAGNOSIS 

6. Roberts" Fermentation Test. — This is an excellent and 
simple test, being used as follows : Into each of two bottles, 
one of -± onnces, the other of 12 ounces capacity, pour 
4 ounces of urine. Add a piece of fresh yeast the size of a 
walnut to the urine in the larger bottle, which must be closed 
with a cork nicked for the escape of gas evolved by fermentation. 
The smaller bottle must be tightly corked, and the two bottles 
placed side by side in a uniform temperature of 68° to 75° F. — the 
average temperature of the room. At the end of twenty-four 
hours, fermentation will be completed. The specific gravity of 
each specimen must then be carefully taken by means of the 
urinometer, and any difference of the specific gravity will indi- 
cate sugar, the number of degrees of difference indicating the 
number of grains per fluid ounce. For example, if the specific 
gravity of the unfermented urine is 1.035, and that of the fer- 
mented urine 1.020, the urine contains 15 grains of sugar to the 
fluid ounce, or 3 per cent. This test, although not absolutely 
accurate, is sufficiently so for practical purposes. 

These six tests represent only a fraction of those in use, but 
are the more important and more simple. The others, among 
them the phenylhydrazin test, are more complicated, and offer 
no advantages over those described. 

Quantitative Tests for Sugar. — For the quantitative deter- 
mination of sugar in the urine, a number of the tests here given 
afford an approximative idea, as, for instance, the Moore -Heller 
and the Koberts tests. The former, however, is not very accu- 
rate, and is of little value if the -amount of sugar is below 1 per 
cent. Fehling's solution may also be used for this purpose, and 
pretty accurate results can be obtained with Einhorn's fer- 
mentation saccharometer. Whitney's reagent likewise gives good 
results. 

1. Fehlixg*s Test.— The principle upon which Fehling's 
solution depends lies in the fact that in the reduction of oxide 
of copper by grape sugar, the blue color disappears by the addi- 
tion of a definite quantity of the sugar. As before said, ten 
cubic centimeters of the solution correspond to 0.05 grammes of 
sugar. The test may be conducted in the following manner : 
Dilute one cubic centimeter of Fehling's solution with four cubic 
centimeters of water in a test-tube, and after heating, add one- 
tenth cubic centimeter of the urine to be examined from a 
graduated pipette. Heat must be then re-applied, the precipitate 



GRAPE-SUGAR 27 

watched, another one -tenth cubic centimeter added, and the heat 
again applied, until after allowing it to stand for a short time, it 
is found that all the blue color is removed from the solution. 
If, in doing this, one cubic centimeter of urine has been added, 
it contaius one-half of 1 per cent of sugar; if more than one 
cubic centimeter, it contains less than one- half per cent, but 
more than one-fourth per cent. If two cubic centimeters are 
used, it contains one -fourth per cent, and if one-half centimeter 
is used, it contains 1 per cent of sugar. If the proportion of 
sugar is large, as is usually the case with a high specific 
gravity, the urine should be diluted five to ten times. 

2. Whitney's Reagent. — This reagent has given good results, 
and for practical testing, ten minims of urine only are used. 
The advantages claimed for it are accuracy, stability, simplicity, 
and reliability. The formula of the standard solution (parts by 
weight) is : 

Grammes 

Ammonii sulphatis (C.P.) 1.2738 

Cupri sulphatis (C.P.) 2.5587 

Potassii hydroxide (C. P.) . . . 19.1620 

Aquae amnion. (Sp. gr. 8.80) 312.2222 

Glycerini (C.P.) 60. 

Aquae (dest.) q.s. 

One cubic centimeter of the reagent is the equivalent of : 

Grammes 

Cupro-diammonium sulphate 0.03832 

Cupric hydroxide 0.41062 

Grape sugar, anhydrous 0.00526 

The following table gives the amounts of sugar in analytical 
testing : 

If reduced by— It contains to the ounce— Percentage 

1 



J. UllUIXli. . . . 


. . J.U. £ 

. . 8. 
. . 5.33 
. . 4. 
. . 3.20 
. . 2.67 
. . 2.29 
. . 2. 
. . 1.78 
. . 1.60 


a 


O.DO 

1.67 


3 " . . . 


It 


1.11 


4 " . . . 


i i 


0.83 


5 " . . . 


it 


0.67 


6 


I I 


0.56 


7 "' . . . 


i i 


0.48 


8 


ti 


0.42 


9 " . . . 


I i 


0.37 


10 


tt 


0.33 



The method of procedure is the following : Heat one drachm 
of the reagent in a test-tube to boiling ; add the urine slowly, 



2^ UBIXAEY AXALYSIS AXD DIAGNOSIS 

drop by drop, until the bine color begins :; fade, then more 
slowly, boiling three to five seconds after each drop, until the 
reagent is perfectly colorless, like water, or until ten drops only 
are added. On cooling, the reagent resumes the blue color, the 
change being due to the absorption of oxygen from the atmos- 
phere. When the urine contains a large amount of albumin, the 
reduction takes place without interference by the albumin 

se nt. but leaves the reagent more or less of a yellow tint. A 
large amount of coloring matter has a similar effect. If the 
urine contains a considerable amount of sugar, it is best to dilute 
it from one to ten times, multiplying the amount found in the 
table by the amount of dilution. 

3. Einhorn's Fee^iestatiox Saccrarometeb.— One of the 
simp.—- tests, ~hieh will be found to answer all purposes, is by 
means of Einhorn's fermentation saeeharonieter. Th^ apparatus 
is put up in the form of a set, consisting of two saeeharoine t > 
and one graduated test-tube. The method is the following: 
Take one gramme (about fifteen grains ) of fresh commercial com- 
st, and shake thoroughly in the graduated test-tube 
with ten cubic centimeters of the urine to be examined. Then 
pour the mixture into the bulb of the saccharometer. By in- 
clining the apparatus, the mixture will easily flow into the cylin- 
der, thereby forcing out the air. Owing to the atmospheric 
pressure, the fluid does not flow back, but remains there. Leave 
the apparatus undisturbed for twenty or twenty-four hours in a 
room of ordinary temperature. 

I: :he urine contains sugar, the alcoholic fermentation begins 
in about twenty to thirty minutes. The evolved carbonic acid 
gas gathers on the top of the cylinder, forcing the fluid back 
into the bulb. On the following day the upper part of the 
cylinder will be found filled with carbonic acid gas. The changed 
level of the fluid in the cylinder shows that the sugar reaction 
has taken place, and indicates, by the numbers upon the cylinder 

~hieh it sponds, the approximate amount of sugar pres- 

ent. If the urine contains more than 1 per cent of sugar, it 
must be diluted with water before being tested ; urine of a 
specific gravity : 1 018 to 1.020 may be diluted twice; of 1.021 
to 1.028, five times ; 1.029 to 1.038, ten times. 

In carrying out this test, it is always advisable k take, 

"he urine to be tested, a normal specimen, and make the 

same fermentation test with it. The mixture of the normal 



GRAPE- SUGAR 29 

urine with yeast will, on the following day, have only a small 
bubble on the top of the cylinder. This proves at once the 
efficacy and purity of the yeast. If, in the suspected urine, there 
is also a small bubble on the top of the cylinder, no sugar is 
present ; but if there is a much larger gas volume, we are sure 
that the urine contains sugar. 

It may be mentioned that the urine may, in rare cases, con- 
tain other saccharine substances, such as lactose, levulose, and 
inosite, but they are of no practical importance. 



Chaptee V 

OTHER ABNORMAL CONSTITUENTS 

Acetone. — Acetone is found in varying amounts in febrile 
conditions, in diabetes, in some malignant tumors, in cases of 
starvation, and in psychoses. It is said to be present in minute 
amount in many normal urines, and is greatly increased by a 
meat diet. 

It may be detected by Ziehen's iodoform test as modified by 
Ralfe : Dissolve twenty grains of iodide of potassium in a 
drachm of liquor potassse and boil ; float the urine upon the 
surface of the fluid in a test-tube. At the point of contact, a 
precipitation of phosphate will occur, which, if acetone be present, 
becomes yellow and studded with yellow points of iodoform. 

Another method of detection is by Legal' s test : Prepare a 
fresh, strong solution of sodium nitro-prusside by dissolving a 
few fragments in a little water in a test-tube. To a few cubic 
centimeters of the urine add enough liquor sodse or liquor po- 
tassae to secure a distinct alkaline reaction, and to this add a 
few drops of the nitro-prusside solution, when a red color will 
at once appear. This color will quickly disappear, but if 
acetone is present, the addition of a few drops of concentrated 
acetic acid will produce a purple or violet -red ; if no acetone is 
present, the latter change will not occur. 

Diacetic Acid. — In advanced stages of diabetes, diacetic acid 
is not Uncommon, and is usually of grave significance. It may 
occur in severe fevers, and also in nervous disturbances. 

The best test is the one described by v. Jaksch : To fresh 
urine carefully add a few drops of a moderately strong watery 
solution of chloride of iron. If a precipitate of phosphates is 
produced, remove it by filtration, and to the filtrate add more of 
the chloride of iron solution. If a red color develops, heat a 
portion of the urine to boiling, acidulate a second portion with 
sulphuric acid, and extract with ether. If the urine which has 
been boiled shows little or no change, while the chloride of iron 

(30) 



OTHER ABNORMAL CONSTITUENTS 31 

reaction with the ethereal extract pales after twenty -four to 
forty-eight hours, and the urine as well as the distillate contains 
large quantities of acetone, diacetic acid is present. 

Coloring Matters. — Bile Pigments. — When biliary coloring 
matters appear in the urine, the urine always has an abnormal 
color — dark yellow, brown, or greenish, and a j-ellow froth or 
foam is produced by shaking. The coloring matters are bili- 
rubin and biliverdin, and are met with in the urine in jaundice, 
from whatever cause it arises, as well as in numerous pathologi- 
cal conditions of the liver, with or without jaundice. They 
may, furthermore, appear as a result of blood- changes, and after 
haemorrhage into the tissues. 

One of the best methods for detecting bile -pigments in the 
urine is by Gmelin's test, which consists of placing a small 
quantity of strong nitric acid, containing a little yellow nitrous 
acid, into a test-tube and gently floating a similar amount of 
urine upon it. If biliary coloring matters are present, a set 
of concentric colored rings will appear at the point of union 
between the acid and the urine ;• these rings, from above down- 
wards, will be green, blue, violet, red, and yellow, the green 
being the most predominant, and is indispensable in proving 
the presence of bile, the others being sometimes more or less 
indistinct and even entirely absent. A moderate amount of 
albumin has no influence upon this reaction. 

A modification of this test by Roseribach is also good : The 
urine is filtered through pure white filtering paper, and, after 
filtration, a drop of the acid is applied to the inside of the 
filter ; around the nitric acid the same concentric rings will be 
observed. 

Another simple test is Ultzmann's : To ten cubic centime- 
ters of urine add three or four cubic centimeters of a 25 per 
cent caustic potash solution and an excess of pure hydrochloric 
acid. If bile -pigments are present, the mixture assumes a 
beautiful green color. 

Coloring Matter of Blood — Haemoglobin, the coloring 
matter of the blood, may be found in the urine, either enclosed 
in the red blood -globules, in cases of haematuria, or, in rare 
instances, dissolved in the urine, the affection being called 
hemoglobinuria. Haematuria is common, and may occur from 
diseases of any portion of the genito- urinary tract. Hasmoglo- 
binuria, on the other hand, is only found occasionally in severe 



32 UEIXAEY ANALYSIS AND DIAGNOSIS 

infectious diseases, especially yellow fever ; in extensive burns, 
and poisoning by different substances, such, as carbolic acid, 
phosphorus, and naphthol ; also, as a disease by itself, called 
paroxysmal hemoglobinuria . 

The simplest method of detecting haemoglobin chemically is 
by Heller's test: The earthy phosphates are precipitated from 
the urine by the addition of caustic potash and heat j as they 
become precipitated they carry with them the coloring matter. 
and are therefore not white, but blood -red. Under the micro- 
scope the coloring matter can easily be detected, whenever 
present in any form. 

Urobilin. — Urobilin is present in small amount in every 
normal urine, but may be abundant in different pathological 
conditions, especially those in which a rapid destruction of red 
blood- corpuscles takes place. The urine will in such cases have 
an intense reddish brown color, similar to that containing 
bile -pigments. 

It can be detected in the following manner : Render the 
urine alkaline by the addition of ammonia ; filter, and to the 
filtrate add a few drops of a 10 per cent chloride of zinc solution. 
If urobilin be present, a green fluorescence will be observed by 
reflected light. 

Indican. — Indican is undoubtedly present in minute amount 
in every normal urine, is increased by a meat diet, is found in 
intestinal disturbances and in a number of widely different 
disea^s. though its pathological significance is not yet under- 
stood. Having frequently been found in persons suffering from 
malignant tumors in any part of the body, but more especially 
the liver, it was at one time considered to be characteristic of 
such tumors : but this is undoubtedly incorrect. In general, it 
may be said that large amounts of indican in the urine are 
caused by an increased albuminous putrefaction in the in- 
testines. 

Its detection by Jaffe's method is the following : Pour into 
a test-tube a small quantity of urine, and mix with an equal 
amount of strong hydrochloric acid : add ten or fifteen drops of 
chloroform and, drop by drop, a moderately strong fresh solu- 
tion of chloride of lime, shaking after each drop. The chloro- 
form readily dissolves the freshly formed indigo, and a blue 
color appears, which is more or less pronounced, according to 
the amount of indican present. 



OTHER ABNORMAL CONSTITUENTS 33 

Fatty Matters. — In rare cases a varying' amount of fat, 
rendering the urine more or less turbid, may be found. Such a 
condition, in which the fat is present either in a state of 
minute subdivision or in the form of larger oil -drops, is called 
Lipuria when no albumin is present, or Chyluria, when a large 
amount of albumin is found with an abundance of small fat- 
globules. The microscope will, of course, reveal its presence at 
once. Chemically, the addition of ether quickly dissolves the 
fat, and the urine becomes clear. 



Part Second 
MICROSCOPICAL EXAMINATION 



Part Second 
MICROSCOPICAL EXAMINATION 



Chapter VI 

GENERAL CONSIDERATIONS 

Whenever urine is to be examined under the microscope, it 
should be set aside iD a well stoppered bottle or conical vessel, 
preferably in a cool place, for at least six hours, but better 
twelve. At the end of this time it will be seen that in every 
urine, even if perfectly normal, a sediment has appeared at the 
bottom of the bottle, which is to be used for microscopical 
examination. This sediment, in normal urine, will be in the 
form of a cloudy deposit, and consists of mucus, flat epithelia 
from the bladder and vagina, and a varying number of epidermal 
scales from the genital organs. Spermatozoa may be present in 
both male and female urine after sexual intercourse, and in the 
former after nocturnal emission. It may, furthermore, contain a 
number of different salts, the character of which will greatly 
depend upon the diet, their number depending upon the degree 
of concentration of the urine. It will be found that the sediment 
of normal urine may contain even a large number of salts in 
the early morning, when the urine is highly concentrated, while 
these salts may be almost entirely absent at other times. 

After standing for some time, every urine undergoes a change, 
the rapidity of which depends upon the temperature as well as 
upon the reaction when passed. An acid urine, which will be 
perfectly clear when passed, may become turbid upon cooling, 
owing to the presence of a large amount of urates. Micro- 
organisms, especially of the class of hyphomycetae, or mould- 
fungi, and saccharomycetae, or yeast -fungi, may sooner or later 
develop, and in a small degree, schizomycetae, or fission -fungi. 
A neutral or even slightly alkaline urine may be clear when 
voided, but will soon become more or less cloudy, the change 

(37) 



URINARY AX ALT SIS AND DIAGNOSIS 

depending partly upon the salts, but mostly npon the develop- 
ment of bacteria belonging to the class of fission -ftmgi. This 
change takes place quickly in warin weather, and is, as a rale, 
more pronounced in the urine of females than in that of males, 
on account of the bacteria, which are normally found in the 
vagina . 

In pathological mine, the sediment will always be more 
abundant than in normal urine, though in mild cases the dif- 
ference is not pronounced. In severe cases, however, it may be 
very abundant, this being due to pus -corpuscles, blood -corpuscles, 
epithelia. casts, etc.. which it contains. Frequently such urine 
will be cloudy when voided, and when an excessive amount of 
mucus is present, will be ropy iu character. 

Use of Centrifuge. — To overcome the necessity of waiting 
for precipitation to take place, the centrifuge has of late 
years been considerably used and highly recommended. Much 
has been said for the centrifugal method, and at times it 
undoubtedly has its advantages ; but. as a rule, it is better to 
adhere to the old method and wait for six hours, the only pre- 
cautions necessary being to keep the bottle tightly corked and in 
a cool place. 

One of the chief advantages of the centrifuge is that bacteria 
are thrown down in large numbers, so that the search for them is 
more successful. This is especially pronounced in eases :: 
tuberculosis, as tubercle bacilli are found more readily iu cen- 
trifuged than in non-centrifuged urine. 

On the other hand, the great force necessary to effect sedi- 
mentation will undoubtedly change some of the minute particles 
to a greater or less degree. In a number of cases, some of the 
pus -corpuscles have been seen to assume different forms, partly 
irregular in character and partly commencing to break down, 
not present in the non-centrifuged urine, though their number is 
the same in both. The same can be said of the different epithelia 
and the spermatozoa, which latter have been seen to assume 
peculiar forms after the use of the centrifuge. The number of 

- has never been found to be appreciably different, though 
her-. s me have undergone changes. Mucus -threads are more 

abundant and more likely to take on the form of cyliudroids. and 
this has and to be quite pronounced in healthy urines, in 

which no pathological features were present, though these 
cylindroi i resemble h valine casts to such a degree as to 



GENERAL CONSIDERATIONS 39 

be easily mistaken for them. Extraneous fibers, such as cotton- 
fibers, have been seen to break into minute fibrillar, and to 
resemble connective -tissue shreds, when the latter are not 
present. 

When care is exercised in microscopical examination, and 
only the perfectly distinct features are taken into consideration, 
the centrifuge can be used ; but, with the sole exception men- 
tioned, does not present any advantages over the old method. 

Mounting of Sediment. — The urine, in an amount of at 
least four or six ounces, having been allowed to stand at rest for 
the required time, the upper portion is carefully decanted or used 
for chemical tests, and a drop of the lower sediment transferred 
to a slide for microscopical examination. Although a glass 
pipette can be used for this purpose, it is simpler to pour the 
sediment into a small dish and use a camel's hair brush to trans- 
fer a drop to the slide. Such a brush can be thoroughly cleansed 
with water after each examination, and is kept clean easier than 
a pipette. The drop of urine is put into the center of the slide, 
and a cover- glass slowly dropped upon it, great care being taken 
not to press the cover down, since eveu the small amount of 
force used may be sufficient to change the epithelia or casts. 

Use of Antiseptic Substances. — In order to avoid decompo- 
sition of the urine as much as possible, when it can not be 
examined within twelve or twenty -four hours after being passed, 
large numbers of antiseptic substances, such as salicylic acid, 
chloroform, thymol, formaldehyde, and bichloride of mercury have 
been recommended to be added in small amount to the urine ; but 
when not absolutely necessary, it is better to avoid them. Urine 
kept in a cool place and in a clean bottle can be examined, even 
thirty- six hours after being voided, without the danger of having 
to deal with too many putrefactive changes. In all cases, the 
chemical analysis should be made as soon as possible. The 
sediment for microscopical examination can be mixed with a little 
alcohol, if necessary, or still better, chromic acid. 

Preservation of Sediment. — If it is desired to preserve a 
specimen for a variable length of time, the best method is to 
add from two to five drops of a 5 per cent chromic acid solution 
to it ; the only change that will take place is that the albumin 
becomes coagulated, appearing, under the microscope, in the 
form of irregular granular matter, irregularly scattered through- 
out the field. The chromic acid will preserve all the features 



40 URINARY ANALYSIS AND DIAGNOSIS 

permanently, not even causing any changes in the casts. Per- 
manent microscopical or slide -specimens are made by adding a 
few drops of chemically pure glycerin to a small amount of the 
sediment previously treated with chromic acid, until a jelly-like 
mass is formed, and waiting for a few days until all the super- 
fluous water has evaporated. It is not advisable to add the 
glycerin to the sediment mixed with chromic acid until the 
watery constituents of the urine have become evaporated, which 
will be the case at the end of one or two weeks. If the sedi- 
ment has become too thick on account of the evaporation, a 
little more glycerin is added, a drop then mounted upon a 
slide, a cover -glass placed upon it, and the whole surrounded by 
asphalt. Specimens preserved in this manner can be kept for 
many years without change. 

Should it be desired to preserve a large amount of the 
urinary sediment in a bottle, the chromic acid is added as 
before ; but in that case it will be better to add a larger 
amount of a weaker solution (about 1 or 2 per cent). After 
a few weeks the upper part of the liquid is poured off, and a 
small amount of a 40 or 50 per cent solution of alcohol added, 
to prevent the growth of mildew. Microscopical specimens can 
be made years afterwards from urine so preserved, by taking a 
drop of the sediment, mixing it with a drop of glycerin, and 
mounting upon a slide in the regular manner. 

Magnifying Powers. — Great difficulty is frequently encoun- 
tered in seeing all the features present in a specimen of urine 
under the microscope, this being in many cases due to the want of 
a proper magnifying power. For the study of urine, the mag- 
nifying power should always be between 400 and 600 diameters, 
the average being 500. A good one -sixth dry lens (make imma- 
terial), together with a one -inch eye -piece, will be all that is 
required. An Abbe condensor should not be used, except for the 
study of bacteria, nor will an immersion lens be always necessary 
even then. Both tubercle bacilli and gonococci can be seen with 
a power of 500 diameters, if the specimen is well stained, 
although a somewhat higher power, 700 to 800, which can be 
obtained by using a one -eighth dry lens, is undoubtedly superior. 
Should it be desired to use an immersion lens for the study of 
bacteria, an Abbe condensor is essential. The custom of trying 
to find casts with a lower power, 150 to 200 diameters, can not be 
recommended, since it is impossible to recognize the other fea- 



GENERAL CONSIDERATIONS 41 

tures present in the case with such a power, and there are many 
cases of great importance in which no casts are present. In 
studying' a case under the microscope, it will be found of great 
advantage to keep a record of all the features as they are found, 
and also to note their comparative numbers. Sketches of the fea- 
tures will still further simplify the stud\ r . Too much stress can 
uot be laid upon the fact that, in the study of epithelia, the com- 
parative sizes of corpuscles and epithelia can alone lead to correct 
diagnoses, so that the advantages of rough sketches can readily 
be appreciated. 



Chapter VII 

CRYSTALLINE AND AMORPHOUS SEDIMENTS 

The crystalline and amorphous or chemical sediments found 
in urine are mostly the different acids and salts, though a 
number of other unorganized sediments may also be present. 



I. ACIDS AMD SALTS 

The salts which may be found under the microscope are seeD 
partly in acid and partly in alkaline urine, and the sediments 
are the following : 

A. ACID SEDIMENTS 



1. Uric Acid 

2. Urate of sodium 

(a) Amorphous 
I C rystaHine 

3. Oxalate of lime 

4. Cystine 

5. Creatinine 

6. Hippnrie Acid 

7. Leucine 

8. Tyrosine 



^ Common. 



[ Bore. 



To these we might add (9) sulphate of lime, which, howevei 
is extremely rare. 

B. ALEALINE SEDIMENTS 



1 . Triple phosphates or ammonio-magnesian 
phosphates 
(a) Complete 
Incomplete 
Simple phosphates or phosphate of lime 

(a) Amorphous 

[b) Star- shaped, or stellate 
Urate of ammonium 

4. Carbonate of lime. 

{a) Amorphous. 

(6) Crystalline, in combination with 
magnesium salts. 

5. Phosphate of magnesium. — Very Bore. 

42 



• Common,. 



Bore. 






CRYSTALLINE AND AMORPHOUS SEDIMENTS 



43 



A. ACID SEDIMENTS 



1. Uric Acid. — Uric acid is a constant ingredient of the 
urine, and is frequently seen nnder the microscope. Its amount 
is greatly increased after a rich, nitrogenous diet, more especially 




Fig. 2. Crystals of Uric Acid, Common Form (X 400). 



of meat, and after physical exercise. It is also augmented in 
acute febrile diseases and in impeded function of the heart, 
lungs, and kidney. It is diminished in profuse secretion of the 
urine, and in the more severe cases of nephritis. When present 
in small quantities, it may be held in solution. 



44 



rBIXAEY ANALYSIS AXB DIA&XOSIS 



Uric acid varies greatly in shape and size, and is of a yellowish 
brown or reddish brown color, except when precipitated in very 
thin plates, when its color is pale yellow, or it may appear almost 
colorless. It may be divided into three principal varieties: 




Fig. 3. Crystals of Uric Acid, Common Form (X-±00j, 



(a) The common form ; (b) as seen in over -acid urine : 
(c) gravel from the pelvis of the kidney. When present in 
larger amount, it becomes precipitated in the form of reddish 
masses, producing the so-called brick dust -sediment. 

The common form of uric acid (see Fig. 2) consists of 
rhomboidal prisms — lozenge shape. The lozenges may be large 



CRYSTALLINE AND AMORPHOUS SEDIMENTS 



45 



or small, single or multiple, with round or pointed ends, and 
at times quite irregular. There may be two lozenges together, 
giving the twin form, or they may be • seen either half -edge or 
edgewise, or they may be in more or less regular barrels. Be- 




Fig. 4. Crystals of Uric Acid, from Over- acid Urine (X450). 



sides these, complicated formations, crosses, and rosettes, are 
seen (see Fig. 3), the latter being a conglomeration of lozenges, 
either in front -view or edgewise, and frequently smaller crystals, 
sometimes quite irregular, are found within the larger ones. 

The second form (see Fig. 4), is often seen in over -acid 
urine, and is usually found with gouty or rheumatic processes, or 



46 



URINARY ANALYSIS AND DIAGNOSIS 



with the formation of uric acid concretions in the bladder. 
These crystals appear in peculiar spear, comb, and brush shapes, 
or in exaggerated lozenges. The spear shapes are, in many 




Fig. 5. Uric Acid Gravel (X 500). 

cases, very pronounced. In persons in whom the so-called uric 
acid diathesis exists, these forms are frequently seen. 

The third variety of uric acid (see Fig. 5), is the so-called 
gravel, which originates in the pelvis of the kidney. Here we 
meet with concretions of varying sizes, irregular plates, masses, 
and needles, either single, double, or conglomerated in the form 
of stars. Occasionally dumb-bell forms are also met with. The 
passage of such gravel, when at all abundant, is almost inva- 



CRYSTALLISE AND AMORPHOUS SEDIMENTS 47 

riably accompanied by more or less severe pain. When in larger 
masses, we have the uric acid calculi or stones, which form the 
largest number of renal stones, being, perhaps, 70 per cent of all 
calculi passed. 

Quite frequently we may have any two, or even all three, of 
these varieties of uric acid combined, in large numbers, together 

W *•* m%. it *dg # 
*>«* * M .#• mm&, 




Mi % WW ;i 




Fig. G. Urate of Sodium, Amorphous (X 500). 

with a varying amount of urates and oxalate of lime crystals. 
When these features are present, the diagnosis of Lithcemia is 
justified. 

Although in almost all cases there will be no difficulty in 
recognizing uric acid under the microscope, there may be ex- 
tremely thin, practically colorless lozenges or irregular plates 
which might be mistaken for phosphates. In order to ascertain 
their exact character, a small amount of some alkali, such as 
caustic potash or soda, may be added while the specimen is 
examined under the microscope, when the crystals will be seen 
to dissolve readily. If now a drop or two of acetic acid be 
added, small characteristic crystals will soon reappear. 

Urate of Sodium. — Urate of sodium (see Fig. 6), when 
present in large amounts, forms the so-called clay -water sedi- 
ment, which renders the urine turbid upon cooling. It may be 
found alone or in combination with uric acid and urate of 



48 



U BINARY ANALYSIS AND DIAGNOSIS 



potassium, from which it can hardly be distinguished. Such 
a sediment is the so-called sedimentum lateritium. Urate of 
sodium usually consists of groups of light or dark brown, fine, 
amorphous granules in a moss -like arrangement, which easily 
adhere to foreign substances as well as to mucus and epithelia. 
The groups vary greatly in size, and are at times quite large. 

This salt is of common occurrence, and will be found in all 
slight febrile derangements, after mental and physical exertion, 
in colds, catarrhs of the stomach and intestines, on the first day 
of menstruation, and in general malaise ; and it may also occur in 
perfectly healthy individuals where the urine is highly concen- 
trated. It is held in solution while the urine is warm, but 
quickly becomes precipitated upon cooling. It is the effete 
material of oxidation, the so-called materia peccans of old 
physicians. 

In rare cases urate of sodium is crystalline (see Fig. 7), 
appearing in the form of needle -like clusters or arranged like 
sheaves of wheat, or of a fan -shape arrangement, pointed toward 




1 

Fig. 7. Urate of Sodium, Crystalline (X 500). 



the center, and broader toward the periphery. This sediment 
has been found in various conditions, such as diseases of the 
stomach and intestines, and in healthy individuals during pro- 
longed physical exertion. The accompanying illustration was taken 
from a case of dermoid cyst of the kidney, where the crystals 
occurred in large numbers with uric acid crystals. 



CRYSTALLINE AND AMORPHOUS SEDIMENTS 49 

Urate of sodium frequently undergoes a change a few hours 
after the urine is voided, the length of time required for the 
change depending upon the temperature. The granules com- 
mence to change into small brown globules, which are either 
single or grouped in twos ; the latter soon coalesce, and form 
small dumb-bells, which gradually enlarge (see Fig. 8). This is 




Fig. 8. Urate of Sodium in Transition to Urate op Ammonium (X 500). 

the first stage of the formation of urate of ammonium, the urate 
of ammonium in statu nascenti, and denotes a commencing transi- 
tion of the original acid sediment into an alkaline. When the 
alkaline change is more or less complete, we have the fully formed 
globules of urate of ammonium. 

3. Oxalate of Lime. — Calcium oxalate, when present in 
small or moderate amount in the urine, without an increase of 
specific gravity, has no clinical significance. Oxalic acid, nor- 
mally present in all urine in small quantities, has a special 
affinity for calcium, and appears in the urine as oxalate of lime. 
It is frequently found after eating certain kinds of fruits and 
vegetables, such as apples, oranges, bananas, certain berries, 
grapes, tomatoes, rhubarb, asparagus, spinach, and turnips. 

It occurs in a variety of forms (see Fig. 9), but it is always 
colorless, and of a high refraction. The most common forms are 
those of quadrilateral octahedrons, greatly varying in size, with 
single or double lines running from one end of the crystal to the 
other, crossing each other in the center and giving the charac- 



50 



UBINAEY ANALYSIS AND DIAGNOSIS 



teristic so-called letter- envelope shape ; when these are seen 
edgewise the octahedral form is more marked. These regular 
forms often commence to break down, so that the lines become 
lost. A number of these crystals may be arranged together, 




Fig. 9. Oxalate of Lime Crystals (X 500). 



either in twos, giving the twin form, or in groups of three, four, 
or more. With these we often see small, more or less regular 
squares or dot -like irregular formations, the so-called amorphous 
shapes. A number of small squares may combine together, 
giving concretions sometimes of large size, which are especially 
abundant under the microscope when oxalate of lime calculi are 
present. They are often massed together upon mucus -threads or 
foreign substances. Besides these, there are rarer forms, con- 



CRYSTALLINE AND AMORPHOUS SEDIMENTS 



51 



sisting of more or less concentrically striated discs or barrel- 
shapes, and of variously sized dumb -bells. The latter may 
assume large proportions, and are easily differentiated from the 
dumb-bell forms of uric acid or urate of ammonium, by their 
being colorless. 

Oxalate of lime crystals can hardly be mistaken for anything 
else, if it is borne in mind that they are always without color 



vO 




Fig. 10. Cystine Crystals (X 500). 

and of a high refraction. Although usually present in acid urine 
only, they may be found in neutral or slightly alkaline urine in 
small amount. When the reaction of an originally acid urine has 
become alkaline, they may be transformed into triple phosphates. 
Should there be any doubt as to their character, they will be 
found to be insoluble in acetic acid, but soluble in muriatic acid. 

When oxalate of lime is present in large amount, with a high 
specific gravity, 1.028, 1.030, or even 1.040, it often denotes the 
existence of Oxaluria. This affection, although very common, is 
frequently overlooked. It gives the symptoms of neurasthenia, 
dyspepsia, melancholia, general malaise, headaches, and ill- 
defined pains in the lumbar region. Those afflicted are usually of 
sedentary habits, and are accustomed to live well. In rare cases, 
especially when concretions of considerable size are present, 



52 



URINARY ANALYSIS AND DIAGNOSIS 



hematuria, often severe and protracted, is a pronounced symp- 
tom. It may last for months, but its cause can at once be 
ascertained by an examination of the urine. As soon as the 




Fig. 11. Creatinine Crystals (X 500). 

patient's diet is regulated, and he takes considerable outdoor 
exercise, the oxalates decrease and the symptoms will improve. 
With such cases inflammation of the pelvis of the kidney, and 
sometimes, also, of the kidney proper, though, as a rule, mild in 
character, is of common occurrence. 

4. Cystine. — Cystine is a comparatively rare sediment, but 
may produce concretions in the bladder. It consists (see Fig. 10) 
of hexagonal, colorless plates of moderate sizes, of high refrac- 
tion, which, in side-view, present one perfect facet and two 
imperfect neighboring facets. A number of plates may lie to- 
gether, one upon another, or they may form more or less regular 
masses. It is readily soluble in ammonia, one of the features 
distinguishing it from uric acid, and contains considerable 
sulphur as a constituent. 

Cystine seems to occur in all members of certain families 
instead of uric acid ; in such families it appears to replace uric 
acid, and in them cystine calculi are not rare. 

5. Creatinine. — Creatinine, normally present in the urine 
in very small amount, is found under the microscope in rare 




CRYSTALLINE AND AMORPHOUS SEDIMENTS 



53 



instances only. It consists (see Fig. 11) of colorless prisms or 
plates, partly lozenge- and partly barrel -shaped. Frequently 
there will be two, three, or even more plates, one within the 
other, or the plates may conglomerate in groups. Occasionally, 
more particularly when the urine has stood for some time, pecu- 
liar configurations will appear in the interior of the plates. 

Creatinine is found most frequently after prolonged muscular 
exercise, as is seen in athletes during active training. A rare 
sediment, found in the urine of a perfectly healthy athlete, is 
shown in Fig. 12. This sediment contains plates and lozenges of 
creatinine, the rare crystalline form of urate of sodium, and 
peculiar formations, consisting partly of fan -shaped and partly 
of angular crystals, from which a varying number of long needles 
are seen to emanate. Some of these crystals resemble rarer forms 
of urate of ammonium, 

Clinically, creatinine has been found in cases of severe acute 
parenchymatous nephritis, associated with urgemic convulsions, 




Fig. 12. Sediment in the Urine op an Athlete (X 500). 



and has also been seen in the urine of females suffering from 
puerperal eclampsia. 

6. Hippuric Acid. — Hippuric acid, which is present in all 
normal urine, is almost always held in solution, though it may 



54 



UEIXABY ANALYSIS AND DIAGNOSIS 



be found in small amount after a vegetable diet, and after eating 
certain fruits, such as cranberries and plums. In the urine of 

herbivorous animals, especially in horses, it is of common occur- 
rence. It will be found in larger amount after the administration 




13. Hippukic Acid iX 500). 



of benzoic acid, or one of the benzoates : also, sometimes, in 
diabe 

It consists (see Fig. 13) of variously sized, colorless prisms 
and plati - m conglomerated into larger or smaller masses. 

The plates may be thin and extremely long, at times resembling 
needles. Hippuric acid might occasionally be mistaken for some 



CEYSTALLIXE AND AMORPHOUS SEDIMENTS 



55 



forms of phosphates, but can easily be differentiated from them by 
its insolubility in acetic acid. 

7, 8. Leucine and Tyrosine. — Leucine and tyrosine are rare 
sediments, and usually occur together. They are never seen 
in normal urine, but mostly in severe acute and usually fatal 




Fig. 14. Leucine and Tyrosine (X 500). 



diseases of the liver, such as acute yellow atrophy of the liver, 
yellow fever, and phosphorus poisoning. They have also been 
found in cases of small -pox, scarlet fever, and typhoid fever. 

Leucine (see Fig. 14) appears under the microscope in the 
form of flat, yellowish or brown globules of different sizes, with 
delicate radiating and concentric striations. Tyrosine is found 



56 



URINARY AXALYSIS AND DIAGNOSIS 



in the form of needle - shaped crystals, grouped in clusters or 
sheaves, crossing at various angles. 

Both leucine and tyrosine somewhat resemble fat, the former 
the fat -globules, the latter the needles of fat— so-called margaric 
acid,— but differ from fat by being insoluble in ether. 




Fig. 15. Complete Triple Phosphates (X 500j. 



9. Sulphate of Lime. — Sulphate of lime has been de- 
scribed as occurring in the urine in an extremely small number 
of cases. It consists of thin, colorless prisms or needles, either 
single, in groups, or in rosettes, resembling crystalline phosphate 
of lime, but more regular. Its clinical significance is not known. 



CRYSTALLINE AND AMORPHOUS SEDIMENTS 
B. ALKALINE SEDIMENTS 



57 



1. Triple Phosphates. — Triple phosphates, the combined 
ammonio-magnesian phosphates, may be divided into complete 
and incomplete. They may be fonnd nnder the microscope in 
small numbers in urines which still give a slightly acid reaction, 




Fig. 16. Incomplete Triple Phosphates (X 500). 

but invariably denote a change to alkalinity. When present in 
large numbers, the urine is always alkaline. Acid oxalate of 
lime is frequently seen to undergo a transformation into alkaline 
phosphates. As all urates are colored to a greater or less de- 
gree, all phosphates are invariably colorless. 



58 URINARY ANALYSIS AND DIAGNOSIS 

Complete triple phosphates (see Fig. 15) are colorless, trian- 
gular prisms or rhomboidal crystals, highly refractive, with 
beveled ends,— the so-called coffin -lid shapes. They vary greatly 
in size and shape, the latter being different when the crystals 
are seen in front-, side-, or top- view. Some of the smaller ones 
can hardly be differentiated from oxalate of lime crystals. 

Incomplete triple phosphates (see Fig. 16) are seen in many- 
forms and sizes. It seems that these crystals are in part not yet 
fully developed (especially the smaller varieties, which may in 



'e*OiO o O 0O,nOO. ' O •"'' O ' n '. <>.•'' . • ' o • o 
Jo' O 0. .' n o'° ° '• &>' °0 *' ' °°" ° • o.o ' 



' 

'- 0" o 
„" n — _ u n - ."- -"-a 


o'o 



o o n oo o O oo;,' > »-o » . „T<*>o „ •» ,„ O 

• 0" o D oo o oo'oo'o °'e . °. * 'o 
°, ' o V °° o. of. . ' £.•„'»•< 

' « .V • /» ° • °°-'° °° - o° : * o oo o 



'»' o e O 



"». • V « 



„ O . • % • , 



•o o <>• ..,'•, <>«, . " 



;••/.••.•-.» -, •- • o'\°- - •;'• • * o*' ' ^ 
•:•."•. *\v*&: ; <:\ *V /. •.' ,° % 

» •»>, •' ; V 0.*. ". '•* •Oft, « o %0 'o" 
o; 9 ° °A /'* • ' ' 0°. • V " • * Q» °0 ° ° 

o:°°'oo b ?' . o-.'oo.o o o° 6 .;-/ ^ » ofc 

•o'o * o »Jo'o«'» , V 5° °o 00 ° >'o 

Fig. 17. Amorphous Simple Phosphates (X 500). 

time grow and become complete), and in part have become broken 
down from previously complete forms. All the different transi- 
tions can be seen in the same specimen when it is studied on two 
or three successive days, which can easily be done by simply 
adding a drop of glycerin to the urine upon the slide. The 
incomplete forms represent irregular plates, either without any 
interior marks or with irregular lines, the result of the transfor- 
mation of the complete crystals. The crystals may be broken 
down in the center, or there may be peculiar cross -like formations, 
or even irregular star-shaped crystals, which can be likened to a 
fern leaf. 

Triple phosphates may be found in varying numbers in 
uormal urine after a vegetable diet. Their amount is greatly 
increased in chronic inflammatory conditions of all kinds, in 
rheumatic processes, in inflammation of the bones, etc. They are 



CRYSTALLINE AND AMORPHOUS SEDIMENTS 



59 



especially abundant in cases of chronic cystitis, where an alkaline 
putrefaction of the urine takes place in the bladder, and may be 




Fig. 18. Star-shaped Simple Phosphates (X 500), 



precipitated in large, flaky deposits, the urine having a pro- 
nounced amnioniacal odor. 

2. Simple Phosphates. — Simple phosphates, or phosphates 
of lime, are of two distinct varieties : first amorphous, and 
second star-shaped or stellate. 

Amorphous simple phosphates (see Fig. 17) appear in the 
form of highly refractive, colorless globules or granules, either 
single or clustered together in variously sized groups, but never 



60 URINARY ANALYSIS AND DIAGNOSIS 

in a rnoss-like arrangement, as the nrate of sodium. These 
phosphates are abundantly found after a milk diet, as well as after 
drinking different alkaline mineral waters. 

Star- shaped or stellate simple phosphates, although of less 
frequent occurrence than the other variety, are by no means rare, 
and are often found in conjunction with the triple phosphates. 
They consist (see Fig. 18) either of slender, colorless rods, or of 
pointed spiculse of various sizes, at times containing smaller ones 
in their interior. Although they may be found single, their 
characteristic grouping is in the form of stars or rosettes, more or 
less complete. The spiculse, of which the rosettes are composed, 
are united in the center of the rosette, while each spicula may 
have a uniform diameter, or be broadened at the periphery and 
narrowed in the center. 

Much has been written about the significance of the phos- 
phates in the urine, and great stress has been laid upon their 
continual increase or diminution, the latter being said to be of 
constant occurrence in cases of nephritis. It is an undeniable 
fact that the phosphates will be diminished in severe and usually 
advanced cases of nephritis, but not more so than the other salts, 
there being a pronounced decrease of all salts in such cases. 

In rare cases, there is a continual increase of the phosphates 
in the urine, without any apparent cause. Such cases have been 
designated by the term PhospJiaturia, and they may give similar 
symptoms to those of oxaluria. The phosphates precipitating in 
the urine being frequently secondary formations, such a diagnosis 
must only be made when their amount is found to be greatly 
increased immediately after the urine is voided, and the presence 
of inflammatory conditions of any kind in the body can be 
excluded. A change of diet will often rectify this trouble in a 
short time. All phosphates are easily soluble in acetic acid, 
which will quickly clear up any doubt as to their character. 

3. Urate of Ammonium. — Urate of ammonium is a common 
sediment in alkaline urine, especially in connection with triple and 
simple phosphates, and is seen in fresh urine only when it is 
passed in an alkaline condition. It is the result of an alkaline 
change of either urate of sodium or uric acid. It appears (see 
Fig. 19) in the form of brown globules of various shapes and 
sizes, usually exhibiting pronounced concentric and radiating 
striations. The globules may appear singly or in clusters, some- 
times forming large, coalesced masses. They are either smooth or 



CRYSTALLINE AJSD AMORPHOUS SEDIMENTS 



61 



provided with thorny, sometimes branching and curved offshoots, 
—the so-called thorn-apple shapes. The offshoots vary greatly in 
size and number, there being either one or many upon a single 
globule. When uric acid changes to urate of ammonium, the 
masses are large and irregular, at first showing the lozenge shape 
of the uric acid, but gradually becoming transformed. Not 




Fig. 19. Urate op Ammonium (X 500). 



infrequently the globules, especially the smaller ones, will con- 
glomerate so as to form concretions, sometimes of large size, and 
this may also be the case when mucus-threads or foreign sub- 
stances, such as cotton- or linen -fibers, are present. 

The alkaline change, which may take place in an originally 
acid urine, is illustrated in Fig. 20. When the urine was voided 
it contained nothing but a large number of uric acid crystals of 
different forms, both plates and needles, some groups of urate of 
sodium, and crystals of oxalate of lime. After about twelve 



62 



URINARY ANALYSIS AND DIAGNOSIS 



hours fermentative changes commenced to appear, and fungi, in 
the form of conidia and mycelia, developed. The urate of 
sodium granules were now found to have partly changed into 
small globules and dumb-bells, the first formed urate of ammo- 




Fig. 20. Acid Sediment in Fermentation and in Transition to Alkaline 

(X 500). 
U, uric acid plates ; UN, uric acid needles ; US, urate of sodium in transition to urate 
of ammonium j UA, urate of ammonium ; O, oxalate of lime ; C, conidia ; M, mycelia. 



nium in statu nascenti. This change gradually continued until 
larger globules of urate of ammonium, as well as more irregular 
forms, had developed. Triple phosphates had not formed. 

4. Carbonate of Lime.— Carbonate of lime is a rare alka- 
line sediment, occurring either alone or in combination with the 



CRYSTALLINE AND AMORPHOUS SEDIMENTS 63 

phosphates. It is usually found (see Fig. 21) in the form of 
amorphous granules and globules of small size, though larger 
than the globules of amorphous simple phosphates, either singly 
or in groups of varying sizes, and of very high refraction. 
Occasionally dumb-bell forms are also seen. Besides the amor- 
phous variety, it occurs in combination with magnesium salts, in 
crystalline shape, as small, delicate prisms, somewhat resembling 

a O o o Q QQO o p Q* O 



° 'I A "Vi? $® Q 



Fig. 21. Carbonate of Lime (X 500). 

the small plates of incomplete triple phosphates. By adding an 
acid, such as acetic acid, effervescence is produced, which also 
occurs in the presence of ammonium carbonate, though this is 
always held in solution, and never seen under the microscope. 
Carbonate of lime is the most common sediment in herbivorous 
animals, and the turbidity of their urine is due to its presence. 

This salt appears mainly in inflammatory and carious pro- 
cesses of the bony system, such as osteitis, osteomyelitis, osteo- 
malacia, and rhaehitis. It may also be found in diabetes and 
phthisis. After drinking certain mineral waters in large quantities 
it may be seen in the urine. 

5. Phosphate of Magnesium.— Phosphate of magnesium is 
an extremely rare sediment, producing colorless, highly refrac- 
tive, elongated, quadrilateral prisms. It is observed in the urine 
after the internal use of the fixed alkali -carbonates, such as are 
held in solution in many mineral waters. 



64 



URINARY ANALYSIS AND DIAGNOSIS 



II. OTHER UNORGANIZED SEDIMENTS 

Fat. — Fat, in the form of globules and granules, is of com- 
mon occurrence in the urine, but care must be taken not to con- 
found it with extraneous fat -globules, which, in many cases, are 
larger, more irregular, and of a more yellowish color. If fat is 
not present in too large quantities, the microscopical appearance 
of the urine is not changed, but if it exists in large amount, as, 
for instance, in the rare cases of Chylnria, in connection with 
considerable albumin, the urine is turbid or milky when voided, 
and after standing, a peculiar creamy layer will' appear at the top 




Fig. 22. Fat-globules and Margaric Acid Needles (X 500). 



of the urine. When fat -globules are voided in such large quan- 
tities as to be seen with the naked eye, and albumin is either 
entirely absent or present in small amount only, the diagnosis 
Lipuria is justified ; these cases are, however, just as rare as those 
of chyluria. The addition of a few drops of ether will clear up 
the urine to a certain degree. 

Fat -globules and -granules vary considerably in size (see 
Fig. 22). When the larger globules are found, needles of mar- 
garic acid may also be present ; these are long, slender formations, 
in which a double contour can be seen only in rare instances. 
They lie between the globules as well as within them in some 
cases, and may also appear to emanate directly from them. 



CRYSTALLINE AND AMORPHOUS SEDIMENTS 65 

Fat -globules have a high refraction, and usually a rather dark 
contour. 

Leaving out of consideration the rare cases of chyluria and 
pronounced lipuria, the latter of which has been observed in 
healthy individuals temporarily after a highly fatty diet, as well 
as in pregnant women and cases of phosphorus poisoning, the 
appearance of a small or moderate number of small fat -globules 
and granules, either singly or in variously sized groups, is seen in 
all cases in which a chronic inflammation, even of mild character, 
exists somewhere in the genito- urinary tract. These globules are 
not only found lying free throughout the different fields, but in 
varying numbers within the epithelia and pus -corpuscles, being 
undoubtedly a secondary product of the protoplasm. The 
globules may make their appearance in small numbers a few 
weeks after the commencement of the inflammation, but will be 
found in greater quantity only in chronic cases ; the more nu- 
merous the globules, the more pronounced the inflammation. At 
first, one or two glistening globules of very small size are seen in 
the granular protoplasm, which condition becomes more and more 
pronounced, until the fatty degeneration, in severe cases, attacks 
the whole of the epithelium, occasionally changing its ap- 
pearance completely. 

Such fat -globules will, therefore, be found not only in 
chronic cases of nephritis and pyelitis, but also in cystitis, pros- 
tatitis, urethritis, and vaginitis. In the different varieties of 
nephritis, their numbers vary greatly. When present in small or 
moderate numbers only, no other diagnosis than that of a chronic 
inflammation is justifiable ; but if very abundant, either with or 
without the presence of fatty casts, a diagnosis of fatty degen- 
eration can be made. 

Cholestearin. — Cholestearin, a normal ingredient of bile, is 
occasionally found in the urine. It consists (see Fig. 23) of 
colorless, thin, irregular rhomboidal plates, frequently broken in 
different parts, and of greatly varying sizes. It easily dissolves 
in ether, and takes on a reddish or violet color if treated with 
iodine and a drop of a sulphuric acid solution. 

Cholestearin has been found in a few cases of chronic cystitis, 
in rare cases of chronic parenchymatous nephritis with fatty 
degeneration, and in chyluria. Its exact significance is 
unknown . 

Haematoidin. — Haematoidin crystals seem to be the result of 



66 



URINARY ANALYSIS AND DIAGNOSIS 




Fig. 23. Cholestearin Crystals (X 400). 

extravasated blood, if retained within the tissues. They appear 
in the urine (see Fig. 24) in the form of small, irregular plates, 




^ 



&fo'A 



Fig. 24. Hjematoidin Crystals (X 500). 

as well as needle-shaped, sometimes stellate, crystals of a reddish 
brown, or rather rust-brown color. The needle-shaped crystals 
vary considerably in size, and may be found either singly or in 



CRYSTALLINE AND AMORPHOUS SEDIMENTS 67 

conglomerations of peculiar forms. Not only may the needles be 
arranged so as to form bunches resembling the bristles of a 
brush, but an irregular mass may be surrounded by a large num- 
ber of needles, sometimes giving a crab -like appearance. The 
larger formations are rare, while the smaller are comparatively 
common, not only lying free, but also in the interior of pus- 




Fig. 25. Indigo Crystals (X 500). 

corpuscles and epithelia. Their presence' always denotes a haem- 
orrhage, which has taken place at some previous time, and they 
may, therefore, be found in a variety of different lesions. 

Besides haematoidin, it is claimed that bilirubin may be found 
under the microscope, closely resembling the crystals of haema- 
toidin, and seen in both plate and needle form. They are usually 
larger and more irregular than the former, and their relationship 
is still undecided. 

Indigo. — All normal urine contains a small amount of indican, 
and the indigo occasionally found in the urine is, as a rule, a 
secondary product of oxidation, often seen when putrefactive 
changes have developed. In rare cases the urine has a bluish 
color when voided, the indigo having been formed in the body ; 
this is seen in pathological conditions only. 

Indigo (see Fig. 25) is seen in the form of blue rhomboidal 
crystals of small size, or irregular masses, as well as in needles 
and thin plates. Although it was formerly always considered to 
have a pathological significance, it is now known to be present in 
perfectly normal conditions. It is not uncommon to see indigo 
under the microscope in small amount as extraneous matter from 



68 URINARY ANALYSIS AND DIAGNOSIS 

the underwear, and this can not, in most cases, be distinguished 
from that formed in the urine. 

Melanin.— Another coloring matter which at times is seen in 
the urine is melanin, appearing as dark brown, or perfectly black, 
irregular granules or masses of small size. It has been found in 
melanotic tumors, such as sarcoma and cancer, as well as in 
broken down constitutions due to various troubles, and can not be 
said to have any special significance. 

URINARY CONCRETIONS 

Quite frequently concretions may form in the urinary pas- 
sages and be found in the urine. When very small, these concre- 
tions are called gravel; when large, stones or calculi ; the former 
can be passed in large amount with little or no pain, the latter 
cause great suffering, and the condition may require surgical 
interference. Concretions are formed either in the kidney, pelvis, 
or bladder, and most frequently consist of uric acid, urates, 
oxalate of lime, or phosphates. Besides these, concretions of 
cystine and carbonate of lime, as well as indigo and xanthin, 
may be found. 

Concretions may consist of one ingredient only, or of two or 
more in alternate layers. The majority of concretions have a 
central portion or nucleus, and a peripheral portion, or body. 
The nucleus varies in size and composition. It may consist of the 
same material as the body, though, as a rule, some organic pro- 
duct, such as a blood -clot or mucus -thread, will form the nucleus, 
around which the body of the calculus forms. In rare cases, 
foreign bodies introduced into the bladder from outside become 
the nuclei of stones. 

The most common are the uric acid concretions, which may 
be passed in large amount in the form of gravel, but often 
attain a large size. They compose from 70 to 80 per cent of all 
concretions, and are formed either of uric acid alone or combined 
with the urates ; are hard, and have a yellowish brown or red- 
dish brown color. Oxalate of lime concretions have a grayish 
color, and may be either small, round, and smooth — called hemp- 
seed calculi, — or large, rough masses, — the mulberry calculi. 
Sometimes the nucleus of these concretions consists of uric acid. 
Phosphatic concretions are usually formed of mixed triple phos- 
phates and phosphate of lime. They are mostly of large size, 



CRYSTALLINE AND AMORPHOUS SEDIMENTS 69 

and have a grayish white color. Other concretions are of rare 
occurrence. In many cases their nature can easily be determined 
by placing a minute particle in a drop of glycerin under the 
microscope. 

Although the presence of concretions, even when very minute, 
can almost invariably be determined by microscopical examination 
of the urine, a number of examinations must not infrequently 
be made before the diagnosis becomes positive. The first urine 
examined maj^ contain a small number of salts only, or these 
may be entirely absent under the microscope, though subsequent 
examinations will show them in large amount, and clear up 
any doubt. In all such cases inflammations or haemorrhages 
from the kidney, pelvis of kidney, or bladder will sooner or 
later develop. 



Chapter VIII 



BLOOD -CORPUSCLES AND PUS -CORPUSCLES 



I. BLOOD-CORPUSCLES 



Bed blood -corpuscles or -globules are of frequent occurrence 
in the urine, and may be derived from any portion of the genito- 
urinary tract. When present in small numbers, the color of the 
urine will not be changed, but when they occur in large numbers, 
the urine has a reddish hue, and may be of a dark red color. 
Although their appearance almost invariably indicates some 




o 
o 

a 

Q 

o a 



ff 'a ° 




Fig. 26. Blood-Cokpuscles (X 500). 

abnormal condition, however slight, it must never be forgotten 
that they are present in female urine at the time of men- 
struation . 

Red blood -corpuscles, as found in the urine, vary considerably 
in appearance, shape, and size (see Fig. 26). In fresh urine they 
are discoid bodies of a yellowish hue, and frequently crenated, 

(70) 



BLOOD-CORPUSCLES AND PUS-CORPUSCLES 71 

but after a few hours only, may have entirely lost their haemo- 
globin, and are then practically colorless. This change takes place 
quickly in alkaline urine, but more slowly in acid urine. When 
the specific gravity of the urine is low, they are frequently 
colorless when voided. As long as they contain considerable 
haemoglobin, they have a yellowish color ; as soon as they com- 
mence to lose their coloring matter, a double contour can always 
be seen, the interior being in most cases apparently structureless. 
This is the condition in which they are most frequently found. 

When they are present in large numbers, they are found both 
singly and conglomerated in variously sized masses, and the so- 
called thorn-apple shapes are often seen. When they lie edge- 
wise, they appear biscuit -shaped, and may be found in small 
masses like rolls of coin ; the latter is comparatively rare in 
urine. As a rule, they are neither granular nor nucleated, and 
can thus easily be distinguished from pus -corpuscles, even if the 
double contour is not well marked. In acid urine, however, after 
it has been standing for a few days, a small number may appear 
granular. 

Urine containing blood -corpuscles invariably contains albumin, 
and the greater the number of blood -corpuscles the more marked 
the albumin. In severe cases of haematuria, the amount of 
albumin may reach one-half of 1 per cent or more, and still the 
kidneys be perfectly normal, the blood coming, perhaps, from the 
bladder, the urethra, or the prostate gland. 

When the urine is of a low specific gravity, the red blood- 
corpuscles frequently imbibe water, swell up, and become hydropic. 
In such cases they are large, pale, double -contoured bodies, and 
are called "ghosts." On the other hand, a varying number of 
small corpuscles are seen in every haemorrhage, which are some- 
times less than half the size of the regular corpuscles, but per- 
fectly characteristic. These are of recent formation, are in pro- 
cess of growth, and are called haematoblasts, a name given to 
them in 1872 by Carl Heitzmann, and in 1878 by Hayem. 

Whenever a large number of red blood- corpuscles is present 
in the urine, a small number of white Mood -corpuscles or leucocytes 
is invariably seen. They vary in amount, but average one of the 
latter to 400 or 500 of the former. Leucocytes can not be dis- 
tinguished from pus -corpuscles. They are usually found in the 
form of globular, granular bodies, though they may easily change 
their form on account of the contractility of their protoplasm. 



72 URINARY ANALYSIS AND DIAGNOSIS 

When a haemorrhage is present, and these corpuscles are seen in 
small numbers only, they should not be called pus -corpuscles. 

In an active haemorrhage, we frequently notice, besides blood- 
corpuscles, fibrin as well as clots of Hood (see Fig. 27). 

Fibrin appears either in the form of thin, pale, colorless 
strings, or larger, more or less reddish or brown masses, fre- 




Fig. 27. Fibrin and Blood-clot (X 500) 



quently giving off smaller branches. It always consists of wavy 
bands, having a higher refraction at the periphery than in the 
center, and having a characteristic appearance. When large, the 
masses can easily be seen with the naked eye. In rare cases, 
such as severe haemorrhages due to tumors or parasites, they 
may attain enormous size, and not infrequently form regular 
casts. 

Blood-dots consist of irregular, rust-brown or dark masses, 
varying in size, and composed of disintegrated blood-corpuscles ; 
they may be so dense that their structure cannot be made out, and 
they must be diagnosed from their color. 

When blood -corpuscles, even in small numbers, are present in 
the urine, it is absolutely essential to discover their source. This 
can only be determined by the nature of the epithelia in the 
urine. As loug as the haemorrhage is not too severe, epithelia can 



BLOOD-CORPUSCLES AND PUS-CORPUSCLES 73 

always be found without any difficulty, but in the worst cases of 
hematuria, epithelia may be present in small numbers only, and 
sometimes many drops of urine must be examiued before their 
source can be positively determined. Even in these cases, how- 
ever, epithelia will be found. The color, reaction, and specific 
gravity of the urine, as well as the nature of the haematuria, can 
never afford any positive clue as to the source of the blood. 

The pathological conditions in which blood -corpuscles are 
found are numerous. They are present in small or moderate 
numbers in every acute inflammation, whether of mild or severe 
character, and even in plain irritations or hyperaemias. They 
will be found in a prostatitis as well as in a nephritis, also in 
pyelitis and cystitis. The presence in the urine of an abnor- 
mally large amount of salts may be sufficient to set up an 
irritation of the kidney or pelvis, with the appearance of blood- 
corpuscles. 

Regular haemorrhages from the genito- urinary organs are 
also of comparatively frequent occurrence and due to many 
causes. Perhaps among the most frequent of these cases are 
haemorrhages from the pelvis of the kidney, often due to gravel 
or calculi. Severe inflammations, abscesses, ulcers, tumors, 
stricture of the urethra, or traumata of different kinds, as well 
as parasites, will cause them. A little care exercised in discov- 
ering all the features present in the urine will, in most cases, 
lead to a positive diagnosis of the source of the haematuria. 

II. PUS-CORPUSCLES 

Whenever pus -corpuscles are present in the urine, even in 
small numbers, w T e can be certain of an abnormal condition 
somewhere in the genito -urinary tract. If they are very scanty, 
we need not necessarily have an inflammation to deal with, 
though there is undoubtedly an irritation in some portion of the 
tract. As soon as they are found in at least moderate numbers 
the diagnosis of an inflammation can at once be made, which is 
the more pronounced, the greater the number of pus -corpuscles, 
and when extremely numerous we may even be justified in diag- 
nosing suppuration, though not without other features. 

Urine containing pus -corpuscles in small numbers may 
appear perfectly normal to the naked eye, but the greater their 
number the more turbid it becomes, and in urine in which they 



74 URINABY ANALYSIS AXD DIAGNOSIS 

are abundant a heavy, cloudy sediment will sink to the bottom 
in the course of a few hours. In such cases the term Pyuria 
might be properly used. Every mine in which pus -corpuscles are 
present in any appreciable number will contain albumin, no 
matter from what organ they are derived, and the larger the 
number of pus -corpuscles the greater the amount of albumin. 

Pus -corpuscles are derived not only from the connective - 
tissue cells, but also to a great degree from the epithelia them- 
selves, the protoplasm of which becomes changed by endogenous 



® * * m m 

* • \ * * t 

'" -^ f ••%H 

W& £ #• # 9 • 

Fig. 28. Pus-corpuscles (X 500 j. 

F, pus-corpuscles with fat-globules : C, ciliated pus-corpuscles ; H, pus-corpuscles with 
haematoidin crystals. 

new -formation to inflammatory corpuscles, which later reach the 
surface of the epithelia and are carried along by the urine as 
pus -corpuscles. They appear mostly as small, round, granular 
bodies, perhaps twice the size of normal red blood -corpuscles, 
in which one or more nuclei may or may not be seen ; but in 
freshly passed urine not infrequently exhibit active amoeboid 
changes, assuming a variety of irregular forms (see Fig. 28). 

In dilute, as well as in highly alkaline urine, the pus-corpuscles 
- w^-11 and assume a large, globular shape, becoming hydropic. In 
these a central nucleus will be observed, while the granulations 
around the peripheral portions become pale or almost entirely 
disappear. In ammoniacal urines, as seen in chronic cystitis, the 
pus-corpuscles, when present in large numbers, burst and coalesce, 




BLOOD-CORPUSCLES AND PUS-CORPUSCLES 75 

producing a sticky mass, which can be transferred to the slide only 
in jelly-like lumps. In such cases, a large amount of mucus is 
always present, and it may become almost impossible to differen- 
tiate the pus -corpuscles from mucus -corpuscles. 

The apparent presence or absence of nuclei in the pus- 
corpuscles depends entirely upon the amount of granulation ; in 
coarsely granular corpuscles they are invisible, but become well 
marked when the granulation is fine. Not infrequently a vary- 
ing number of small, glistening fat -globules and -granules will 
appear in the pus -corpuscles, and this fatty change may be so 
pronounced that almost the entire granulation appears altered. 
Such a pronounced change always denotes a chronicity of the 
inflammation, although the fat -globules may commence to ap- 
pear a few weeks after the beginning of the inflammation, when 
the process can not as yet be called strictly chronic. In per- 
fectly acute inflammations, however, they are never found. 

Sometimes pus -corpuscles are seen which contain delicate, 
rust-brown crystals of haematoidin, in both needle and plate form. 
This is more especially the case in those derived from epithelia 
of the pelves of the kidneys and the uriniferous tubules of 
the kidneys, and denotes a previous haemorrhage. In recent 
haemorrhages the pus -corpuscles may have a uniform yellow 
color, due to the imbibition of the coloring matter of the blood. 
In cases of chronic catarrhal cystitis, dark brown pigment- 
granules may sometimes be found in the pus -corpuscles. 
Occasionally pus -corpuscles which have delicate hair -like pro- 
longations — cilia — are seen. These arise from the ciliated co- 
lumnar epithelia of the uterus, and when present justify the 
diagnosis of an endometritis. Care must be taken not to mis- 
take bacteria adhering to the surface of the pus -corpuscles for 
cilia. 

Constitution. — Pus -corpuscles, when present in moderate or 
large numbers, will invariably allow us to form an opinion as 
to the constitution of the patient. All pus -corpuscles are 
granular, the nature of this granulation varying with the con- 
stitution of the individual. This fact was first announced in 
1879 by Carl Heitzmann, and thousands of examinations have 
proved the correctness of his assertion. It is easy to recognize 
the different appearances of the pus -corpuscles, not only in 
different cases, but to a certain degree in the same case, if 
attention is paid to this fact ; some corpuscles appear highly 



76 URINARY ANALYSIS AND DIAGNOSIS 

refractive and coarsely granular, while others are pale and 
finely granular (see Fig. 29). 

Coarsely granular, refractive, nearly homogeneous corpuscles, 
without any apparent nucleus, show an excellent, first-class con- 
stitution, and the more numerous these are in a given case, the 
better the constitution. The coarse granulation is due to a large 
amount of living matter ; the less living matter present, the 
finer will be the granulation, and, therefore, the poorer the con- 
stitution. In persons having a good constitution, the granulation 



rip w IP 

Fig. 29. Pus-corpuscles Showing Different Constitutions (X 500). 
E, excellent ; G, good ; M, medium ; P, poor. 

is still coarse, though not to such a great degree as in those of 
an excellent constitution, and the pus -corpuscles will not appear 
as highly refractive as in the latter. When the granulation be- 
comes less coarse, a nucleus will be seen in the pus -corpuscle. 
This is proof of a medium constitution, while very finely granular 
pus- corpuscles, with one or more pale nuclei, indicate a poor or 
broken down constitution. 

If all the different varieties of granulation, from the coarsely 
granular down to the finely granular, are present, we can come to 
the conclusion that the patient had originally a good, or even 
excellent constitution, which has become weakened by disease, and 
the more abundant the finely granular nucleated bodies are, the 
greater has been that weakening, A few months or weeks before 
the death of an individual, if the same occurs from a chronic 
ailment, or even a very short time before death, if it occurs from 
an acute affection, the pus -corpuscles break down completely, 



BLOOD-CORPUSCLES AND PUS-CORPUSCLES 77 

and become changed to finely granular, pale, irregular masses. 
These facts can be verified in every case, and will be found of 
invaluable aid in the prognosis. A little study, even with no 
higher power than 500 diameters, is sufficient to easily see the 
differences here noted. 

Attention must, however, be drawn to the fact that it is easy to 
confound mucus-corpuscles, which are always pale and finely 
granular, and are present in every normal urine, with pus- 
corpuscles. Mucus -corpuscles are normal products of the epi- 
thelia, vary considerably in size and shape, and are not nucleated ; 
they are, of course, useless in diagnosing the constitution, as are 
hydropic pus -corpuscles. 

Pus -corpuscles may be derived from any portion of the genito- 
urinary tract, and their source can only be determined by the 
nature of the epithelia present in the urine. Being invariably 
found in every inflammation, the mildest as well as the most 
pronounced, they are among the most common of all the elements 
found in the urine. To diagnose an inflammation of the kidney, 
it is by no means necessary to find casts, since a number of 
kidney -lesions, sometimes quite severe in character, exist without 
the presence of casts. Irritation from a large number of salts, 
which is common in the pelvis of the kidney, is sufficient to show 
a small number of pus -corpuscles. Although highly alkaline 
urine frequently accompanies an inflammation of the bladder, no 
positive conclusion can be arrived at without the characteristic 
epithelia. Again, in the urine of a female, a large number of 
pus-corpuscles may be present without any other trouble than a 
vaginitis, though this may be sufficient for considerable amount of 
albumin to appear. The same may be said of prostatitis and 
urethritis. Any doubt as to the origin of the pus-corpuscles will 
at once be dispelled by finding the characteristic epithelia in the 
urine. 



Chapter IX 

EPITHELIA 

With very few exceptions, epithelia present in the urine 
always denote a pathological process of some kind. In normal 
mine the only epithelia to be fonnd are irregular, flat epithelia 
from the bladder, in small numbers, while in urine of females 
there may be flat epithelia from the vagina ; the presence of all 
other epithelia is pathological. Although it is claimed to be 
impossible to diagnose the sources of the different epithelia in 
the urine, this is not at all difficult, provided a few general 
points are always borne in mind ; and it is only by an accurate 
knowledge of their sources that we are able to obtain a diagnosis 
of the location of the morbid process. Most of the morbid pro- 
cesses occurring along the genito - urinary tract are inflammatory 
in nature, and marked by the presence of pus -corpuscles in the 
urine, and the location of the inflammation is determined by 
the epithelia. 

Before speaking of the nature of the different epithelia found 
in the urine, it is necessary to have an idea of the general 
characters of the epithelia occurring in the body. These are of 
three kinds: First, flat or squamous; second, cuboidal ; and 
third, columnar or cylindrical . Flat epithelia are always more 
or less irregular in outline, exhibiting a broad front surface, 
while in edge view they are narrower, and somewhat spindle shaped. 
Cuboidal epithelia have about the same diameter in all directions, 
while columnar epithelia are elongated in one direction. The 
latter may be ciliated, having one or more delicate hair -like pro- 
longations on the outer surface. All epithelia are granular, and 
possess one or more nuclei, which, however, need not always be 
visible, and may have dropped out. leaving a vacuole. The 
granulation may be coarse or fine, the flat epithelia being fre- 
quently more finely granular and paler than the others. 

All epithelia may occur either in a single layer or stratified ; 
that is, there may be a number of different layers. Wherever 

(78) 



EPITHELIA 79 

stratified epithelia occur, and all three varieties are present, the 
flat variety is seen to compose the outer or upper layers, the 
cuboidal the middle layers, and the columnar the inner or deepest 
layer, nearest to the connective tissue. 

In the genito-urinary tract, a lining; of stratified epithelium is 
found in the pelves of the kidneys, the ureters, bladder, urethra, 
vagina, and cervical portion of the uterus, while a simple epi- 
thelial lining exists in the uriniferous tubules of the kidneys, 
the prostate gland, ejaculatory ducts, Bartholinian gland, and 
mucosa of the uterus. 

It is maintained that the epithelia from different organs, such 
as the bladder, ureters, and pelves of the kidneys, are identical in 
size and shape. By scraping off the epithelia of these organs, 
this idea appears correct, but if the epithelia are examined in situ, 
we will soon be convinced that their size varies considerably. 
The largest epithelia are found in the vagina ; the next in size in 
the bladder ; then, in order, those of the cervix uteri, urethra, 
pelves of kidneys, ureters, and prostate gland ; the smallest in the 
uriniferous tubules. It must not be forgotten, however, that 
there are transitional sizes, which are of no value for diagnosis. 
The smallest cuboidal epithelia from the bladder, for instance, 
may be identical with the largest cuboidal epithelia from the 
pelves of the kidneys, but the average size is absolutely different, 
being considerably smaller in the pelves than in the bladder. 
Again, the caudate and lenticular forms of epithelia are far more 
prevalent in the pelves and calices than in the bladder, and are 
well adapted for a diagnosis. 

All epithelia will change to a certain degree in the urine, 
more especially the cuboidal, which are originally angular poly- 
hedral formations ; by the imbibition of the watery constituents 
of the urine they swell and assume a more or less regular, even 
perfectly spherical, form. This change will affect all epithelia 
alike, and the size of the spheres is sufficient for a diagnosis of 
their previous location. 

In the vagina and bladder, where the epithelia are large, the 
difference between the flat, cuboidal, and columnar varieties is 
naturally most marked, while in the pelves, ureters, urethra, 
and cervical portions of the uterus it is not so pronounced. 
In the prostate gland the simple epithelial lining is cuboidal, 
while in the duct of the prostate gland it is columnar. In the 
ejaculatory ducts, as well as in the mucosa of the uterus, ciliated 



80 



URINARY ANALYSIS AND DIAGNOSIS 



columnar epithelia are present, though in the urine the cilia 
break off easily, and may not be seen. In the uriniferous 
tubules of the kidney the simple epithelial lining varies in 
different portions, being partly flat, partly cuboidal, and partly 
columnar ; the flat and cuboidal epithelia can not be distin- 
guished, while the columnar variety is well marked. 

In every urine, flat, horny epithelia from the genitals, — the pre- 
puce in the male, and the clitoris and labia in the female — are 
frequently found, and are called epidermal scales (see Fig. 30). 
They have a jagged contour and a rather high refraction, and do 




Fig. 30. Epidermal Scales (X 500). 

not contain a nucleus, but are frequently studded with dirt -par- 
ticles and fat- globules. In addition, their granulation— if any is 
present at all, which is rarely the case — is extremely pale, and 
they appear more or less shriveled. They vary in size and shape 
considerably, and must not be mistaken for epithelia or crystals of 
incomplete triple phosphates, which latter they sometimes re- 
semble. 

In attempting to diagnose the sources of the different epithelia, 
it must be remembered that nothing but size will positively differ- 
entiate them, and that a small number of epithelia may be found, 



EPITHELIA 81 

the source of which can not be told positively ; the larger number, 
however, are absolutely characteristic. 

The epithelia found in the urine may be divided into : first, 
those common to both sexes ; second, those found only in the 
male ; and third, those found only in the female. 

Epithelia Common to Both Sexes. — The epithelia found in 
both sexes are those from the bladder, the pelves of the kidneys, 
the ureters, and the uriniferous tubules of the kidneys. The 
urethral epithelia are also the same in both sexes, but are most 
common in the male. 

Epithelia from the Bladder (see Fig. 31). — The epithelia from 
the bladder are of three distinct varieties, and are easily recog- 
nizable ; these are flat epithelia from the upper layers, cuboidal 
from the middle layers, and columnar from the deepest layer. 
Flat epithelia may be seen both in front view and edgewise, when 
they may appear more or less folded. A small number of these 
epithelia, without the presence of pus -corpuscles, may be seen in 
every normal urine. They have no significance whatever, since 
the flat epithelia continually desquamate in health, though in a 
small amount only. As soon as they occur with pus -corpuscles 
and with cuboidal epithelia, they have a pathological significance. 
These flat epithelia may be seen either singly or in clusters of 
varying size. Although the size of these epithelia is distinctly 
smaller than that of the epithelia from the upper layers of the 
vagina, a small number may occasionally be found, of almost the 
same size as the latter, coming from the neck of the bladder, near 
the prostate gland. Their number, together with the size of the 
cuboidal epithelia, and the fact of their not containing bacteria, 
will be sufficient to clear up the diagnosis. 

Cuboidal epithelia from the middle layers are never found in 
normal urine ; they may be scanty or numerous. When cuboidal 
epithelia are present in moderate or large numbers, with many 
flat epithelia from the upper layers, the diagnosis of an acute 
process can be made. If, on the other hand, the upper layers are 
scanty or entirely absent, the process is a chronic one. Whenever 
fresh recurrences of an old process set in, the flat epithelia will 
become more numerous. 

Columnar epithelia from the deepest layer of the bladder are 
found only in the severer processes, such as intense inflammation, 
ulceration, haemorrhage, and tumors. Care must be taken not to 
mistake the folded upper layers for these more coarsely granular 



82 



V BINARY ANALYSIS AND DIAGNOSIS 



and highly refractive epithelia— those from the upper layers being 
paler and more finely granular. 

Mention should here be made of an occurrence, which, though 
it may be found in the epithelia of any organ, is most pronounced 




Fig. 31. Epithelia from the Bladder (X 500). 
TJ, upper layers ; UF, upper layers, folded ; M, middle layers ; D, deepest layer. 

in the larger cuboidal epithelia of the bladder. In different 
epithelia from the middle layers, a number of nuclei or even 
newly formed, so-called endogenous, pus -corpuscles will be found. 
Their number varies from two to four, five, or even more. That 
pus -corpuscles are formed within epithelia can be easily observed. 
A few of these new -formations can often be seen in different 



EPITHELIA 



83 



inflammations, but larger numbers will be found in the epithelia 
only after a long -continued irritation through some pressure, usu- 
ally from the outside. Such endogenous new -formations will be 
seen in cases of hypertrophied prostate gland, undoubtedly 
caused by pressure of that organ upon the bladder, as well as in 
different exudations behind the bladder, such as a parametritic 
exudate, or a tumor in the wall or vicinity of the bladder. 

All cuboidal and columnar epithelia may contain a varying 
number of secondarily developed, glistening fat -granules and 








Fig. 32. Epithelia from Pelvis of Kidney and Ureter (X 450). 

-globules similar to those seen in the pus -corpuscles. This is 
invariably an indication that the process has lasted for some 
time, and is not an acute one. A large number of these 
globules always indicates a chronic process. 

Epithelia from Pelvis of Kidney (see Fig. 32). — In the pelves 
of the kidneys the epithelia also vary considerably in shape, 
being partly globular, but mostly irregular. They are smaller 
than those from the bladder, but larger than those from the 
ureters, the epithelia from which latter are almost always present 
with those from the pelves. The majority of the pelvic epithelia 
are caudate, pear-shaped, or lenticular, though they are some- 
times quite irregular ; the regular, cuboidal shapes, smaller 
than those from the bladder, being less numerous. The epi- 



EH 7I.IXJMT AMALYSil ANL DLAGWOSI& 

:hehh H"- ii-r/ienh:- -een ~ :h nri: ::::. gri-ei ~h::i :snses 
on ii": ::;-::'_ :: i_i."i__nn:i :: :he pelvis 

Epithelia from the Ureters. — Epithelia from the ureters are 

mel" iinni ohnf ' :.: nsnallj ~: _ Those iron :he pel~; 
Inen :'_;::■ oeii-Ti: shipe — :he nine := rem! ;: ^hiiili. 
being iisrhicolv snalle: Than those n : '_ :_r pelvis Thej ;in 
not be differentiated from the epithelia of the prostate gland, 

which :'_--/ :iose> resench Then i::oot: in :i: ::;:: is is 2. 




role, small : and the fact of their being associated with epithelia 
fron Th-r kidney and pelvis of kidney ™fep« their diagnosis 

I_ tke&rn from the Urimiferoms Tubules of Kidneys (see Kg. 

— EpiTien;: iron t_t nioofrc os tt. cmes Or t_t nosT ""'.- 
] r::n: : hi The eiiThrh:" ovo'. in "It nrme : _ ". ihose nosT 
n- v T :l;.:>rf. irne-e: ±^7 ne iresen: n The "nit 

~" : -. \" - ■ : ". ; " - :ies o'tL vrhen __ : .0:^ nioT'o: ::-n oe frnni 
_i:sis :: : i-;h::o- is :-iT.-i_ smoe 

1-7 I wc : 1 : ; i __ - ire- found : the enboidal 

:: n The : :.":"titt1 ~":n.es : 1 1 :ir ::hii_i;.i n:n the striihnT 

_ ii: v i - These eii.heh; ?.re hsnmnij snalle: :hm 

•- : 1- ; ii- :: Tie koine 7 :: :he nre:e: in The 



EPITHELIA 85 

same case, though their sizes vary to a certain degree in dif- 
ferent cases. 

In every case examined, the first step is to look for pus -cor- 
puscles, which are known to be small in some individuals and 
comparatively large in others, and are usually the smallest granu- 
lar corpuscles seen. As soon as these are decided upon, the next 
step is to determine whether bodies distinctly larger than these 
are present. If such bodies, one -third larger than pus- corpuscles, 
are found in at least moderate numbers, we can be certain that 
they are epithelia from the convoluted and narrow tubules of the 
kidney. The presence or absence of a nucleus has no significance 
whatever, although such a nucleus is usually found in the kidney- 
epithelia, but may be invisible in the pus -corpuscles. The rela- 
tion between the size of the pus -corpuscles and that of the 
epithelia from the convoluted tubules is always the same ; that 



m w$ 



®@© ^^^ W Wr W 

Fig. 34. Comparative Sizes op Corpuscles and Epithelia (X 500). 

is, the latter are one- third larger than the former. If the pus- 
corpuscles happen to be small in the case examined, the kidney 
epithelia will be small ; but if large, the epithelia will be large. 

The comparative sizes of the different smaller formations found 
in the urine are illustrated in Fig. 34. The smallest corpuscles 
with double contour, and which are not granular, are the red 
blood -corpuscles ; the next in size, being the smallest granular 
corpuscles, are the pus -corpuscles ; then follow the smallest epi- 
thelia found in urine, one -third larger than the pus -corpuscles — 
the epithelia from the convoluted tubules of the kidney. Finally, 
the next larger epithelia are shown, always twice the size of the 
pus -corpuscles, which are either those from the ureters or the 
prostate gland, between which no difference can be noticed. If 
this relationship is kept in mind, no mistake can be made, though 
it must be remembered that when an individual small epithelium 
is found, the diagnosis can not be made positively until com- 
pared with the pus -corpuscles. 

Besides the cuboidal epithelia, columnar epithelia from the 
straight collecting tubules are sometimes found. The latter are, as 



UEIXAEY ANALYSIS AKD DIAGNOSIS 

a rule, not as abundant as the former, and are almost invariably 
seen in larger numbers in the severer cases of nephritis only. 
Their size, as compared with that of the cuboidal epithelia, is about 
the same, they being narrower, but elongated. In very acute eases 
of nephritis, clusters of Mdney epithelia, as well as cast-like tubes 
of epithelia, though not necessarily regular easts, may be found. 

Although it is the usual custom to rely entirely upon the 
presence of casts in the urine before making the diagnosis of a 
nephritis, it will be found that casts are frequently absent, even in 
pronounced cases of kidney inflammations, as, for instance, in 
catarrhal or interstitial nephritis; and that even in cirrhosis of the 
kidney, casts are, as a rule, entirely absent, or if present, are 
extremely scanty. If care is taken to look for epithelia one-third 
larger than pus-corpuscles, the diagnosis of a nephritis can be 
made in many cases which are otherwise overlooked, even 
though a small or even moderate amount of albumin be present 
in the urine. Too much stress can not be laid upon this fact, 
is in many cases where the clinical symptoms undoubtedly 
point to a nephritis, the diagnosis is abandoned, because no 
casts are found. This variety of nephritis is much more com- 
mon than is usually supposed, though in most cases of a milder 
character than the parenchymatous variety, and it may often 
last for a number of years without being detected. 

Epithelia Found in Urine of Male. — The. epithelia found in 
the urine of the male are those from the urethra, the prostate 
gland and its duet, and the ejaeulatory duct (see Fig. 35). 

Epithelia from Urethra. — The epithelia from the urethra vary 
considerably in shape and size, being partly flat, partly cuboidal, 
and partly columnar, and are all comparatively large and irregu- 
lar, so that they can be easily diagnosed in almost all cases. The 
larger irregular, partly flat, partly cuboidal epithelia are seen in 
milder inflammations, such as the first stages of catarrhal or 
gonorrhoea! inflammations; the irregular columnar or cylindrical 
epithelia occur only in deeply seated inflammations or ulcerations, 
which often lead to the formation of a stricture. 

\etia from Prostate Gland. — The epithelia from the pros- 
tate gland are partly cuboidal and partly columnar, the latter 
always originating in the duet of the gland. The cuboidal epi- 
thelia are of exactly the same size as the cuboidal epithelia from 
the ureters, being twice as large as the pus -corpuscles in every 
and distinetlv larger than those from the convoluted tubules 



EPITHELIA 



87 



of the kidney. When epithelia of this size are seen in a given 
case, care must be observed to take the relative numbers of 
these, as well as of those from the convoluted tubules and the 
pelvis of the kidney, into consideration before reaching a posi- 




Fm. 35. 



Epithelia from Urethra,, Prostate Gland, and Ejaculatory Ducts 

(X 500). 
UE, urethra ; PE, prostate gland and its duct ; EE, ejaculatory duct. 



tive diagnosis. For instance, if they are present in large num- 
bers, while those from the kidneys and pelves are entirely absent 
or seen in small numbers only, they are undoubtedly prostatic. 
The clinical history, if known, will, of course, clear up this 
point still further. 

The columnar epithelia from the duct of the gland, which are 
distinctly larger than those from the straight collecting tubules of 
the kidney, are rarely absent in pathological processes of the 
prostate gland, and will render the diagnosis plain, since columnar 
epithelia from the ureters, which they resemble, are not frequently 
seen, and, when present, are usually found in small numbers 
only. 

Mention should also be made here of the fact that in rarer 
cases pale, concentric formations of varying sizes are found with 
the prostatic epithelia. These are the so-called prostatic concre- 
tions, colloid or amyloid corpuscles of the prostate gland (see 



88 



rBIXABY ANALYSIS AXD DIAGXOSIS 



Fig. 36). They are irregular, partly oval, partly angular bodies, 
which have a high refraction and a more or less pronounced 
concentric striation. frequently with an irregular central nu- 
cleus. Their number seems to be augmented in some cases of 
hypertrophy of the gland. 

Epithelia from Ejaculatory Ducts. — Epithelia from the ejacu- 
latory ducts may also be found in the urine. They are of the 




Fig. 36. Speioia as Foexd eh Ublse (X 500). 



columnar ciliated variety, and perfectly characteristic. The cilia 
are not always seen, since they break off easily and become lost ; 
but delicate parallel rods in the interior of the epithelia. near 
their basal surface, may then indicate that the epithelia were 
originally ciliated. When no cilia or rods are found, their size 
alone will usually be sufficient for a diagnosis, as they are smaller 
and considerably narrower than those from the bladder. 

Sperma. — Not infrequently sperma, the characteristic ingre- 
dients of which are the spermatozoa, is found in urine, normal as 
well as pathological. This will be the case after sexual inter- 
course, as well as after emissions, and in spermatorrhoea, which 
latter can best be diagnosed from the almost constant presence of 
sperma in urine, especially the first urine voided in the morning. 
When sperma is fouud in small amount only, the appearance of 
the urine is not changed ; but when present in large amount, 



EPITHELIA 89 

cloudy, flaky deposits are seen, which, when examined, prove to 
be sperm a. 

In urine, the positive diagnosis of sperma can only be made 
when spermatozoa are found, though prostatic epithelia, and 
occasionally spermatic concretions, may be present (see Fig. 36). 
The other ingredients of sperma, such as the sperma-crystals, will 
not be seen in urine. 

Spermatozoa, which are about -fo~o or too of an inch long, 
consist of a flattened, oval, or pear-shaped head, a small cylin- 
drical middle portion or neck, which, however, is not always seen, 
and a long, wavy, tapering tail, considerably broader at the head 
than at the end. In perfectly fresh urine a slight motion of the 
spermatozoa may be visible for a short time, but disappears very 
soon. They are extremely resistent toward chemical reagents, 
and may be found well preserved in urine after days, even when it 
is strongly alkaline. 

The number of spermatozoa in urine varies greatly. Under 
normal conditions the spermatozoa are rarely abundant, while in 
cases of spermatorrhoea they are usually quite numerous, and may 
be present in very large numbers. In cases of spermatocystitis or 
seminal vesiculitis they are frequently seen, and many of them 
will be found changed, the head gradually enlarging, becoming 
more round and often granular. It is not unusual for the head 
to assume the size of a pus -corpuscle, which it may resemble to 
such a degree that it is impossible to differentiate it from the 
latter; in appearance, it is like a pus - corpuscle with a tail. In 
these cases regular pus -corpuscles, epithelia from the prostate 
gland, and frequently, also, from the ejaculatory ducts, will be 
present. 

Urethral and Gleet- Threads. — Although no distinction should 
be made between urethral and gleet- threads (the latter originating 
in the urethra), there are cases in which men who have never 
suffered from gonorrhoea will void small, transparent mucus- 
threads with the first morning urine. These are always scanty, 
and consist of nothing but mucus, both fibers and corpuscles, 
together with the larger, flat, superficial urethral epithelia. These 
masses are conglomerations of mucus in the urethra, and are not 
pathological. 

On the other hand, we find in the urine of persons who have 
suffered from gonorrhoea, at one time or another, either only a 
short time previously or many years before, a varying number of 



90 UBINARY ANALYSIS AXD DIAGNOSIS 

threads which differ in size, and may appear either perfectly 
transparent or more or less opaque. These are the regular 
gleet-threads (see Fig. 37). 

It is not uncommon to find such threads accidentally in the 
urine of persons who, though they suffered from gonorrhoea a 
long time previously, have not noticed any symptoms for years. 
In these cases they are, of course, small and scanty. More 

W0-K 




•ff 







Fig. 37. Gleet-threads (X 500). 
PC, pus-eorpuscles ; M, mucus-fibers ; PE. epithelium from the prostate gland ; DE, epithe- 
lium from the duct of the prostate gland ; UE, epithelium from the urethra. 

frequently are they found in those cases of chronic gonorrhoea in 
which slight symptoms, such as a moisture at the orifice of the 
urethra, or an adhesion of the lips of the meatus in the morning, 
with subsequent discharge of a minute drop of either mucous or 
rnuco-purulent fluid, are present. The number of threads in 
cases of this kind is at times very large. Fortunately, gonococci 
are not found in all these cases, but may be entirely absent in the 
larger number, and repeated careful examinations will fail to find 
them. 

Regular gleet-threads consist of mucus, pus -corpuscles (the 
latter usually abundant in the more pronounced cases), and a 
varying number of epithelia from the urethra and the prostate 
gland ; sometimes, also, from the neck of the bladder. The 



E PI THE LI A 91 

larger number of pus- corpuscles, as well as most of the epithelia, 
will be found studded with fat- globules and -granules, which latter 
are not infrequently seen in smaller or larger groups upon and 
between the mucus, outside of the pus- corpuscles and epithelia. 
The more chronic the case, the more numerous will be the fat- 
globules. The appearance of such so-called gleet -threads under 
the microscope is always perfectly characteristic, though the 
name is misleading, since, when they are large, a number of 
fields will be found crowded with pus -corpuscles, mucus, and 
epithelia not in the least resembling a thread. 

The more severe the case, the more abundant will be the pus- 
corpuscles, and care is necessary in such cases not to make an 
error in the diagnosis, which would be easy when the presence 
of gleet -threads is not suspected. A wrong diagnosis of an 
abscess might thus be made, although such a diagnosis is never 
justified without the presence of a number of connective -tissue 
shreds, which are never seen here. In the milder forms the 
mucus is abundant, and the pus -corpuscles mixed with it often 
change and assume various irregular shapes, the spindle shape 
being frequent. It is impossible to judge of the chronicity of a 
case from these, as has been claimed. Again, the pus -corpuscles 
may swell up and become hydropic, or the cover -glass may have 
been accidentally pressed in mounting the specimen, either of 
which is sufficient to change the appearance of the pus -corpus- 
cles. Spermatozoa may at times be found mixed with the 
gleet -threads, but will, of course, not affect the diagnosis in 
any form. 

Epithelia Found in Urine of Female. — The epithelia found 
in the urine of the female are those from the vagina, the Bar- 
tholinian gland, the cervix of the uterus, and the mucosa of 
the uterus. 

Epithelia from Vagina. — The epithelia from the vagina are 
the largest found in the urine ; those from the upper layers are 
flat, those from the middle layers are cuboidal, and those from 
the deepest layer are columnar (see Fig. 38). 

The flat epithelia are present in varying numbers in most 
female urines, and, when found alone have no significance, since 
they continually desquamate in health. When leucorrhoea is 
present, as is almost always the case, in a small degree, in 
healthy women who have borne children, their number is consid- 
erably augmented. They may be found singly or in variously 



92 



UEIXABY ANALYSIS AND DIAGNOSIS 



sized clusters, and are always large, irregular, and usually studded 
with bacteria,— both cocci and bacilli. They frequently contain 
large fat -globules, which, of course, have here no significance, 
and are often seen folded or edgewise, when they are narrow, 




Fig. 3S. Epithelia from the Vagina iX 500). 
U, upper layers ; U F, upper layers folded : M, middle layers ; D, deepest layer. 

but irregular, and can not be mistaken for columnar epithelia. 
Their granulation is fine, and the epithelia, therefore, pale. 

The cuboidal epithelia from the middle layers are abundant in 
inflammations of the vagina. They are considerably larger than 
those from the bladder, have one or more nuclei, and, in chronic 



EPITHELIA 



93 



inflammations, contain fat -granules and -globules. These are 
also found in clusters of considerable size. 

The columnar epithelia from the deepest layer, much larger 
than those from the bladder, are seen only in intense, deep-seated 
inflammations or ulcerations, where they may sometimes be found 
in large numbers. 

Smegma. — Of common occurrence in the urine of the female 
are clusters of epidermal scales, so-called smegma, partly from 
the clitoris, partly from the labia, or from the vagina. Smegma 




Fig. 39. Smegma from the Clitoris (X 450). 



may also be found in small amount in the male, from the pre- 
puce, but here it is not so common, nor seen in such enormous 
masses as in the female (see Fig. 39). 

Smegma consists of closely packed masses of variously sized 
epidermal scales filled to a greater or less degree with bacteria, 
— both cocci and bacilli, — and also with extraneous fat -glob- 
ules, as well as particles of dirt. The individual scales, as be- 
fore said, are never nucleated and rarely granular, but appear 
shrunken. Such masses, which have been seen to cover an 
entire field of the microscope, are highly refractive, and when 
large can be seen with the naked eye. 

Epithelia from Bartliolinian Gland (see Fig. 40). — The 



94 



URINARY ANALYSIS AND DIAGNOSIS 



epithelia from the Bartholinian gland are in every respect the 
same as those from the prostate gland in the male, being cu- 
boidal and twice the size of pns- corpuscles. They are frequently 
present when the vaginal epithelia are found in moderate or 
large quantities. 

Epithelia from Cervix Uteri.— Epithelia from the cervical por- 
tion of the uterus are partly flat, partly cuboidal, and partly col- 




Tig. 40. Epithelia from Bartholinian Gland, Cervix Uteri, and Mucosa 

Uteri (X 500). 

BE, Bartholinian gland ; CE, cervix uteri ; UE, mucosa uteri. 

umnar, and quite large, though considerably smaller than those 
from the vagina, and always more irregular. These epithelia may 
be characteristic, but they sometimes so resemble the irregular 
epithelia from the urethra, as to be difficult of differentiation. 
The latter are found in the female as well as the male, though 
generally in smaller numbers. 

Epithelia from Mucosa Uteri. — Epithelia from the mucosa of 
the uterus, indicating a catarrhal endometritis, are also hot rare in 
the urine. They are delicate, columnar, ciliated formations, 
smaller than those described as being derived from the ejaculatory 
ducts. The cilia on the surface of these epithelia are frequently 
well marked, and as many as three or four may be found ; 
occasionally, however, they are broken off. With them we may 
see ciliated pus -corpuscles, which arise from the epithelia, and can 



EPITHELIA 95 

not come from any other locality than the uterus. In freshly 
voided urine the cilia from both these formations may be seen in 
waving motion. 

If the epithelia just described are carefully studied, we will 
soon become convinced that the formations from the different 
organs of the genito-urinary tract can undoubtedly be differen- 
tiated, and that diagnoses of the different lesions can be made 
with great certainty. In every case in which at least a moderate 
number of epithelia is found in the urine, most of these are 
characteristic of the organ from which they are derived. There 
will, of course, always be a few whose origin must remain 
doubtful, but these are not sufficiently numerous to cause errors. 
The more cases we examine, the more convinced we will become of 
this fact. The clinical history of the case will bear out the 
microscopical diagnosis every time, and frequently the microscope 
will give the first indication of some pathological condition which 
has as yet escaped detection, but which sooner or later is bound to 
give clinical symptoms. In no organ is this more pronounced 
than in the kidney, where mild cases of nephritis, which unfor- 
tunately escape detection for months or years, may be present, 
until suddenly the pronounced symptoms of a chronic nephritis or 
a cirrhosis of the kidney develop. Conscientious examination of 
the urine for kidney epithelia and pus- corpuscles will often repay 
the physician in cases where, although he has found a trace of 
albumin, he will banish from his mind, all idea of an inflammation 
of the kidneys because no casts are present. 



Chaptek X 

MUCUS AND CONNECTIVE TISSUE 

I. MUCUS 

Mucus is found in small amount in every normal urine, being, 
as a rule, more abundant in females. It appears in the form of 
threads and corpuscles, and is a normal physiological product of 
the epithelia (see Fig. 41). 

Mucus-threads are finely striated, pale, often scarcely percep- 
tible strings of different sizes. In normal urine they are always 
small ; but in inflammations, especially those of the genital tract, 
may assume large proportions. The strings are made up of pale, 
more or less parallel fibers, and when large, may branch in 
different directions. 

Besides threads, mucus -corpuscles are of frequent occurrence. 
These corpuscles vary in size from that of a pus-corpuscle to that 
of larger epithelia ; are pale, more or less irregular in outline, 
always finely granular and non- nucleated. They are easily dis- 
tinguished from pus -corpuscles by their greatly varying sizes, 
pale appearance, and absence of a nucleus, which latter is seen 
in finely granular pus -corpuscles. 

Mucus- threads not infrequently appear in the form of delicate, 
striated formations, resembling casts, the so-called cylindroids or 
mucus-casts (see Fig. 42). Although at times resembling hyaline 
casts, they can be distinguished from them by their irregular 
contours, enormous difference in size, and their more or less 
striated interior, since they are nothing but conglomerations of 
mucus-fibers. They may be found whenever mucus is present in 
larger amounts, and may be derived from any portion of the 
genito- urinary tract. They undoubtedly have no further signifi- 
cance than mucus in general. 

Mucus is greatly augmented in all inflammatory conditions, 
but more especially in inflammations of the bladder and the 
genital organs, such as the urethra, prostate gland, and vagina. 

(96) 



MUCUS AND CONNECTIVE TISSUE 



97 



In the latter, mucus -threads are often large, cylindrical, and 
twisted, and may be perceptible to the naked eye. The so-called 
gleet -threads are nothing but conglomerations of mucus, in which 
large numbers of pus- corpuscles and epithelia are imbedded. 




Fig. 41. Mucus-threads and -Corpuscles (X 500). 



Irritation of the urinary tract, due to highly acid urine, contain- 
ing uric acid and urate of soda, will increase the amount of 
mucus, and the urates being precipitated upon it, the stringy 
masses become more easily perceptible. Fat -granules and -glob- 
ules, so frequently found in the urine, will also conglomerate upon 
mucus- threads and so -called cylindroids. 
G 



98 



UEIXAET AXALYSIS AXD DIAGXOSIS 



Iii chronic inflammations of the bladder, the urine will appear 
ropy on account of the abundance of mucus. Simple irritation 
of the sexual organs is sufficient to increase the amount of mucus, 




Fig. 42. Mucus-casts or Cylixdroids (X 500). 

and if sperma is mixed with the urine, its mucous constituents 
appear as pale, flaky masses entangled with spermatozoa. 

Finally, an increased amount of mucus may be seen in the 
urine in different febrile conditions, without any inflammation in 
the urinary tract, and in acute contagious diseases, such as 
scarlet fever, frequently appears as a precursor of a nephritis. 



MUCUS AND CONNECTIVE TISSUE 99 

II. CONNECTIVE TISSUE 

As all the organs containing epithelia also contain connective 
tissue, it is evident that this formation will frequently be found 
in the urine, though only in the more intense, deeper -seated 
pathological processes. Their occurrence has, however, been 
entirely overlooked, except in the rare cases in which particles 
of tumors, especially from cancers, have been found in the urine. 
That they are of comparatively common occurrence was first 
pointed out by Carl Heitzmann, who described their appearance 
under a number of different conditions. The reason for their 
being overlooked seems to be, partly, that in many cases they 
are small, though easily seen, and partly that they have been 
mistaken for mucus -fibers or extraneous substances, such as 
linen- and cotton -fibers. 

Connective -tissue shreds (see Fig. 43) vary in size, and are 
made up of wavy, highly refractive fibers, the individual fibers 
being rarely single, but conglomerated in the form of small, 
irregular bundles, which again form larger bundles. These bun- 
dles, then, are always fibrillary and frequently finely granular, 
sometimes even containing formations resembling nuclei — the 
connective -tissue corpuscles. They may be so small and deli- 
cate as to entirely escape detection with a magnifying power of 
less than 500 diameters, or so large as to cover half or even the 
entire length of a field, and of varying thickness. They are eas- 
ily differentiated from mucus -threads by their high refraction 
and their wavy, irregular fibers, in contradistinction to the pale 
appearance and more or less regular fibers of mucus, which fre- 
quently run in a parallel direction for a considerable distance. 
On the other hand, linen -fibers, or rather the smaller fibrilhe of 
linen, with which they might also be confounded, are of a still 
higher refraction, and are coarser, the individual fibrillae being 
split up in an entirely different manner, and are never as wavy as 
the connective -tissue shreds. 

The pathological conditions under which connective -tissue 
shreds are found may be divided into the following : (1) Ulcera- 
tion, (2) suppuration, (3) haemorrhage, (4) traumata, (5) tumors, 
(6) hypertrophy of the prostate gland with inflammation of that 
organ, (7) cirrhosis of the kidney, (8) atrophy of the kidney, 
(9) in all intense inflammatory processes, but in small amount 
only. As an example of the latter, the croupous or parenchy- 



100 URINARY ANALYSIS AND DIAGNOSIS 

matous inflammation of the kidney may be mentioned, in which, 
if it is at all severe, connective -tissue shreds will be found in 
small numbers. 

1. Ulceration. — Ulcerative processes are quite common occur- 
rences, and may be found in any part of the genito- urinary 




Fig. 43. Connective-tissue Shreds (X 500). 

tract, but more especially in the bladder, pelvis of kidney, ure- 
thra, and vagina. In such ulcers the connective -tissue shreds 
are usually broad and numerous, pus -corpuscles will be present 
in moderate or fairly large numbers, and the location of the 
ulcer can always be determined by the presence of the charac- 
teristic epithelia, which are abundant, and not only found from 



MUCUS AND CONNECTIVE TISSUE 101 

the more superficial, but also from the deeper layers. Besides 
these formations, the freshly voided urine will contain variously 
sized conglomerations of cocci, in the form of zoogloea masses, 
especially around the connective -tissue shreds, as well as small 
numbers of other bacteria. 

2. Suppuration. — The presence of an abscess in any organ 
can be diagnosed when connective -tissue shreds in large numbers 
are seen with numerous pus -corpuscles and epithelia from the 
organ in which the abscess is situated, this being most frequently 
either the kidney, the pelvis of the kidney, or the prostate 
gland. In many cases we will also see pronounced endogenous 
new -formations in the epithelia of the neighboring organs, as 
the result of pressure upon that organ. An abscess of the 
prostate gland, for instance, may give endogenous new -forma- 
tions in the epithelia of the bladder, as well as of the urethra. 
Large numbers of pus -corpuscles and epithelia alone, without the 
presence of connective -tissue shreds, are never sufficient to diag- 
nose an abscess. As soon, however, as these shreds, showing a 
destructive process, are found, the diagnosis will become plain. 
The connective -tissue shreds, although always quite numerous, 
may vary considerably in size. 

3. Hcemorrhage . — In haemorrhages of the genito- urinary tract, 
it is often quite difficult to find the epithelia showing their 
source — the more abundant the haemorrhage, the greater the 
difficulty. It sometimes requires hours to arrive at a definite 
conclusion, though a certain number of epithelia will always 
be found sooner or later. In all such cases connective -tissue 
shreds are present, but are occasionally quite scanty and 
small, except when the haemorrhage is due to a tumor. They 
have, as a rule, a yellowish tint, from the coloring matter 
of the blood. In haemorrhages red blood -corpuscles are very 
abundant, and white blood -corpuscles are generally seen in small 
numbers. Strings of fibrin, which must not be mistaken for 
connective tissue, are found in many of these cases, but pus- 
corpuscles are absent as long as there is no inflammation ; if a 
haemorrhage intervenes upon an inflammation, all the evidences 
of the latter will, of course, be present with the former. 

4. Traumata. — Since traumata, due to various causes, are 
frequently accompanied by haemorrhages or even ulcerations, their 
symptoms would be those above given. There are, however, 
cases in which the injury does not cause a pronounced haemorrhage, 



102 URINARY ANALYSIS AND DIAGNOSIS 

yet the destructive process to the tissue is sufficient for connective- 
tissue shreds to appear in the urine, with but a few red blood- 
corpuscles. Among these may be mentioned slight injuries, due 
to the passage of a small amount of gravel, mechanical injury of 
the orifice of the vagina due to masturbation, or injuries of the 
cervix uteri. In mechanical injuries, such as are caused by mas- 
turbation, vaginal epithelia from all three layers will be found, 
together with a large number of epidermal scales from the labia, 
usually containing fat -globules, epithelia from the Bartholinian 
gland, a few pus -corpuscles, possibly a few red blood- corpuscles, 
and a small or moderate number of connective -tissue shreds. 
When the number of vaginal epithelia is not large, and con- 
nective-tissue shreds appear with numerous irregular epithelia 
from the cervix, with only a few pus -corpuscles, injuries around 
the cervix are indicated. Although of comparatively small prac- 
tical importance, it must be known that connective -tissue shreds 
in the urine of females may be due to such causes. 

5. Tumors. — In all tumors which can be diagnosed from the 
urine, such as papilloma, sarcoma, and cancer, connective -tissue 
shreds are the most important diagnostic features, without which 
the presence of a tumor can not be positively diagnosed. Besides 
these, other evidences of a tumor are frequently found, though 
the connective -tissue shreds themselves may be characteristic 
enough for a diagnosis. 

In papilloma, such shreds are always large, very irregular, 
frequently branched, and often assume the shape of coils or 
knobs (see Fig. 44). They are coarsely granular, and may con- 
tain a number of inflammatory corpuscles in their interior. In 
rare cases, blood-vessels in process of formation or fully de- 
veloped may also be found in them. Besides these large masses, 
the regular connective -tissue shreds are also present in varying 
amount. A number of irregular, coarsely granular epithelia, the 
covering epithelia of the papilloma, will usually be seen in such 
cases, though they are not found in situ, and are not of much 
value for a diagnosis. 

In cancer of the bladder, especially villous or papillary, the 
connective -tissue shreds are occasionally still larger and more 
irregular, forming regular cauliflower-like excrescences. They are 
infiltrated with inflammatory corpuscles, sometimes to a great 
degree, and often contain large cancer epithelia or even epithelial 
nests. Besides these shreds, such cases contain a varying number 



MUCUS AND CONNECTIVE TISSUE 103 

of epithelia about the size of those from the middle layers of the 
bladder, but extremely irregular, coarsely granular, and having 
numerous nuclei or pus-corpuscles in their interior, — the so-called 
endogenous new -formations. In rarer cases, variously sized 
cancer nests are also present. As a rule, both the connective- 




Fig. 44. Connective-tissue Shreds found in Tumors (X 500). 

tissue shreds and the epithelia are seen crowded with fat-globules 
and -granules. The epithelia alone are never sufficient for a 
diagnosis, but as soon as the shreds just described are present the 
case becomes plain. That pus -corpuscles, bladder epithelia, and, 
usually, red blood -corpuscles are always found in these tumors, is 
evident. 



104 UBINASY ANALYSIS AND DIAGNOSIS 

In sarcoma, which can develop either in the kidney, bladder, 
prostate gland, or uterus, and be diagnosed according to the 
epithelia present, the connective- tissue shreds are frequently of 
very large size, but not characteristic. Here peculiar, glistening, 
coarsely granular, almost homogenous corpuscles, smaller than 
pus - corpuscles but larger than red blood-corpuscles, are found in 
large numbers and variously sized groups. 

6. Hypertrophy of Prostate Gland. — An enlargement of the 
prostate gland, when slight and unaccompanied by an inflamma- 
tion, will not give connective -tissue shreds in the urine. As 
soon, however, as the hypertrophy becomes more pronounced and 
is accompanied by an inflammation, connective-tissue shreds, which 
may be small and scanty, will invariably appear in the urine, with 
pus- corpuscles and epithelia from the prostate gland. Besides 
these features, we will usually find the endogenous new -formations 
in the epithelia of the bladder or urethra, or both. 

7, 8. Cirrhosis and Atrophy of Kidney. — Every chronic 
interstitial nephritis will, sooner or later, lead to cirrhosis of the 
kidney, and every chronic parenchymatous nephritis to atrophy of 
the kidney. In both of these affections, connective-tissue shreds 
are also present, usually in small amount only in cirrhosis, but 
always in larger amount in atrophy. The features found in the 
urine in these diseases, besides connective -tissue shreds, are 
numerous and so constant that a diagnosis is simple. 

9. That connective- tissue shreds will also be found in small 
numbers in every intense inflammation, is evident from what has 
been said. Tuberculosis of the kidney, for instance, even if as 
yet unaccompanied by ulceration, will give a few shreds in the 
urine. As soon as connective- tissue shreds, however small, are 
found, it becomes evident that the pathological process can not be 
a mild one. 



Chapter XI 

TUBULAR CASTS 

Tubular casts were first carefully described as occurring in the 
tubules of the kidney and found in the urine by Henle in the 
year 1842, although they were probably seen a few years before 
that time by different observers. Many years later, in 1867, 
Rovida gave a thorough account of their nature and formation. 
Henle considered them to be coagulated fibrin, but the views con- 
cerning their origin have become greatly changed since that time. 
They were at one time considered as products of secretion of the 
epithelia of the tubules, at another time as transformed or disin- 
tegrated epithelia. Later on, the blood-vessels were supposed to 
be principally concerned in their production, at least in that of 
the hyaline casts, without any participation of the epithelia. 

One of the older views was that casts are produced by the 
coagulation of an albuminous substance, the supposition being 
based upon the fact that the presence of casts in the urine 
depends upon the admixture of albumin, since they are found in 
conditions accompanied by albumin, and the more abundant the 
albumin, the more likely casts will be present. This view seems 
to be nearly correct. Casts are probably the products of an albu- 
minous exudation from the blood-vessels, with the addition of the 
swollen and destroyed epithelia. In almost all cases where casts 
are present, albumin is found in moderate or large amount; but 
there are undoubtedly cases in which the amount of albumin is 
small, and, it is claimed, may even be entirely absent. The 
latter is, however, doubtful. The amount of albumin may be so 
small as to escape detection by che usual chemical methods 
employed ; but, according to the view of their formation, it 
would seem that a small amount, at least, must be present in 
every case. 

The appearance of casts in the urine is always of the highest 
diagnostic importance, and, if found in any amount, they indicate 
the presence of a croupous or parenchymatous nephritis, the more 

(105) 



106 URINARY ANALYSIS AND DIAGNOSIS 

so, the larger the accompanying amount of albumin. It is as- 
serted that a mere hyperemia of the kidneys will suffice to throw- 
casts into the urine, and also that casts can be found in small 
numbers when the kidneys are perfectly intact. They have been 
described in cases of gastro- intestinal catarrh, in jaundice, acute 
and chronic anaemia, as well as in nervous affections of different 
kinds, without any accompanying inflammation of the kidneys. 
As they have been found in very small numbers only in all such 
cases, it is an open question whether true casts were seen, or 
only cylindroids, which at times it is almost impossible to dis- 
tinguish from hyaline casts. Since casts are always the products 
of an inflammatory process, they can hardly be found in plain 
hyperaemia of the kidney, unaccompanied by an inflammation. 

In order to positively guard against any errors in the diag- 
nosis, it is important to always look for other evidences of 
inflammation in the urine, when casts are believed to be present. 
As soon as they are found, the nature of the formations is plain. 
Great difficulty seems to exist sometimes in finding casts, even 
when they are known to exist, since, at times, they will not settle 
for a number of hours. If urine is allowed to stand for at least 
six hours, and is then carefully decanted, the casts, if any are 
present, will surely be found in the sediment at the bottom of 
the vessel. Attention should also be called to the fact that low 
magnifying powers are unreliable for the detection of casts, and 
that a power of at least 400 diameters should always be used. 
Another necessary precaution is to examine more than one speci- 
men before positively determining as to the presence or absence 
of casts. With a little care, the centrifuge can undoubtedly be 
used, but unless it is of great importance to examine a specimen 
of urine at once, the older method is preferable. 

Casts have been divided in many different ways, but, perhaps, 
the simplest is to divide them into true casts and false , or pseudo 
easts. The former alone denote the presence of a nephritis, while 
the latter are accidental formations. 



I. TRUE CASTS 

True tube casts are of six varieties. These are: (1) Hya- 
line casts, (2) epithelial casts, (3) blood casts, (4) granular 
casts, (5) fatty casts, (6) waxy casts. 

Generally speaking, the first three varieties,— hyaline, epithe- 



TUBULAR CASTS 107 

lial, and blood casts, — are found only in an acute parenchymatous or 
croupous nephritis, while the last three, — i.e., granular, fatty, and 
waxy casts, — are found only in a chronic parenchymatous inflamma- 
tion of the kidney. In the first few weeks of the inflammation, 
the last three varieties of casts never appear ; but as soon as the 
absolutely acute attack commences to subside, and the inflamma- 
tion assumes a more subacute form, granular casts, first in small, 
then in larger numbers, are seen, while the hyaline and epithelial 
casts are still abundant. Fatty and waxy casts are always sec- 
ondary products, and are never found until a nephritis has lasted 
for some time, although mixed epithelial and granular casts, com- 
mencing to become fatty, may be found five or six weeks after 
the beginning of the inflammation. 

All true casts may appear in three distinct sizes, according to 
the portion of the uriniferous tubules from which they originate. 
The narrowest casts are those formed in the narrow tubules, the 
next in size from the convoluted tubules of the second order, 
while the largest are always formed in the straight collecting 
tubules. Casts from the convoluted tubules of the first order, 
those directly arising from the capsule of the tuft, never appear 
in the urine, since they can not pass the narrow tubules. 

Although not generally admitted, a great prognostic value 
undoubtedly attaches to the size of the casts. The mildest de- 
grees of the disease are indicated by casts from the narrow 
tubules, and a small number of casts from the convoluted tubules. 
Not infrequently pedunculated casts are met with ; that is, 
formations from the place of transition of the narrow tubules 
into the convoluted tubules of the second order. Casts from 
the convoluted tubules justify the diagnosis of parenchymatous 
nephritis in the cortical substance. Casts of all three sizes, 
the largest arising from the straight collecting tubules, permit of 
a conclusion of parenclrymatous nephritis in the whole organ, 
and upon this condition a very unfavorable prognosis can be 
established. 

Based upon these simple facts, a good or a bad prognosis can 
be given in many cases where the clinical features are too ob- 
scure to be of any practical value, and in a number of cases the 
bad prognosis, which had to be given on account of the presence 
of many large easts from the straight collecting tubules, and 
which did not at first seem justified by the scarcity of clinical 
symptoms, was soon borne out by the fatal end of the case. 



108 



UEIXABT ANALYSIS AND DIAGNOSIS 



That, besides these facts, stress must always be laid upon the 
general eonstitntion of the patient, which, as previously 
explained, can be positively recognized by the appearance of the 
pus -corpuscles, need hardly be mentioned again. A careful 
examination of all the pus -corpuscles present in a given case 







Pig. 45. Hyalint Casts X 500 . 
t s from convoluted tubules ; X, from narrow tubules ; S , from straight collecting tubules. 

will invariably show how much the constitution has been im- 
paired by disease : the paler the pus -corpuscles the more unfa- 
vorable the prognosis, and. therefore, the worse the constitution 
of the patient at the time of examination. 

1. Hyaline Casts ' see Fig. 45). — Hyaline casts are pale 
formations of variable length, sometimes of considerable size, and 



TUBULAR CASTS 



109 



not infrequently difficult of detection in the urine. Those from 
the convoluted and straight collecting tubules are usually more 
or less regular, though the latter may be very broad ; those from 
the narrow tubules are occasionally tortuous or spiral, and at 
times exceedingly narrow and delicate. As a rule, these casts 




Fig. 46. Epithelial Casts (X 500 



C, casts from convoluted tubules ; N, from narrow tubules ; S, from straight 
collecting tubules. 

are absolutely structureless, but at times a pale granulation is 
noticeable in their interior, though this is not sufficiently marked 
to allow of their classification as granular casts. Different for- 
mations, such as pus -corpuscles and fat-globules, may be seen 
upon them in small numbers, but are accidental., and do not 



110 URINARY ANALYSIS AND DIAGNOSIS 

change the diagnosis. In rare cases these casts may appear more 
solid and of higher refraction, though their hyaline character is 
undoubted, and they must not be mistaken for waxy casts. 

"When very delicate and pale, it has been advised to color the 
casts by the addition of a drop of iodine-iodide of potash solu- 
tion (iodine, 1 part ; iodide of potash, 2 parts ; water, 300 parts) 
upon the slide, which will stain them yellow, and render them 
more distinct. This is rarely necessary, since a shaip focus, per- 
haps with the light somewhat shaded, will bring them into view 
quite clearly. In a highly alkaline urine they are indistinct, and 
after a time seem to become lost completely. 

2. Epithelial Casts (see Fig. 46). — True epithelial casts are 
hyaline casts studded with epithelia. The desquamated epithelial 
tubes which are sometimes found in the urine, and represent solid 
masses of epithelia of varying length in the form of casts 
thrown off from the tubules, can hardly be called true casts, 
although they are usually classified as such. 

Epithelial casts, when present, always denote an acute pro- 
cess, and the more pronounced it is, the larger is the number of 
these casts. They vary in size according to their origin, but 
are never as long as some hyaline casts, and are usually quite regu- 
lar. They are of a higher refraction than the former, and can 
T)e easily found. The number of epithelia seen in these casts 
varies considerably. Sometimes no more than two, three, or 
four will be found in a cast, while at other times the cast is 
completely filled with them, though still showing its structure 
plainly. Those from the convoluted and narrow tubules contain 
the spherical epithelia, while those from the straight collecting 
tubules are usually filled with a number of columnar epithelia. 
Occasionally these casts have a yellowish color and a slightly 
increased refracting power, owing to their imbibition of the 
coloring matter of the blood. 

As long as the nephritis is acute, the epithelial casts will have 
the appearance just described, being more or less coarsely granu- 
lar, but with the epithelia perfectly intact. As soon as the 
inflammation enters the subacute or chronic stage, their charac- 
ter changes and fat -globules appear. We can then no longer 
consider them pure epithelial casts. 

3. Blood Casts (see Fig. 47). — The presence of blood-casts in 
the urine always shows a haemorrhage within the tubules of the 
kidney, and when seen in large numbers, the complication is quite 






TUBULAR CASTS 



111 



grave ; but less so in children than in adults. The appearance of 
these casts varies greatly ; they are always more irregular than 
the epithelial casts, their ends more or less rounded, and may be 




Fig. 47. Blood Casts (X 500). 

C, easts from convoluted tubules ; N, from narrow tubules ; S, from straight 
collecting tubules. 

either studded with a varying number of red blood- corpuscles 
without changing their color ; or, if they have been retained in the 
tubules for some time, the blood -corpuscles lose their shape, and 
the casts take on the appearance of dark, rust- brown, granular 
clusters. 

Many of these casts will show transitional forms and have a 
more or less pronounced color. They always indicate an acute 
hemorrhagic process, and usually we find either hyaline or epi- 



112 



URINARY ANALYSIS AND DIAGNOSIS 



thelial casts, or both, with them. Besides these, conglomerations 
of fibrin, the so-called fibrin casts, are occasionally fonnd, bnt, 
properly speaking, they are not true casts. In still rarer cases, 




Fig. 48. Granular Casts (X 500). 

C, casts from -convoluted ubules ; N, from narrow tubules 
collecting tubules. 



S, from straight 



such as haemoglobinuria, casts of haemoglobin, resembling the dis- 
integrated blood casts, but much more irregular and granular, 
and of a darker color, are seen. 

4. Granular Casts (see Fig. 48). — While the three varieties of 
casts just described are always found in acute cases, or fresh acute 
recurrences of chronic inflammations, granular casts never appear 



TUBULAR CASTS 113 

in strictly acute inflammations. As a rule, they will not com- 
mence to be formed until a number of weeks after the beginning 
of the disease ; but in some cases, especially in children after 
scarlet fever and diphtheria, they have been seen in small num- 
bers two or three weeks after the first symptoms of the nephritis 
have set in. 

Granular casts are either perfectly regular and have sharply 
defined contours, or they are more or less curved, or appear curved 
at one side while they are .straight at the other. Their ends are 
either rounded or partly broken, and they may be broader at one 
place and narrower in another — a peculiar^ especially pronounced 
in those from the narrow tubules. Their degree of refraction 
I changes considerably, and they sometimes appear yellowish, at 
| other times colorless. 

The granulation of these casts varies to a great degree, some 
being coarsely granular, others finely granular, still others partly 
the former and partly the latter. They may appear coarsely 
granular at both ends, finely granular in the center, or finely 
granular above and below and coarsely granular in the center, 
I the gradations being many. 

Granular casts are always due to a disintegration of the kidney- 
epithelia, which will commence after a varying length of time. In 
those cases which have not as yet become chronic, the disintegra- 
tion of the epithelia can be studied under the microscope in all the 
different stages. In cases of long duration, the granules become 
changed into glistening fat -granules and -globules. 

5. Fatty Casts (see Fig. 49). — True fatty casts are always 
secondary products of epithelial and granular casts, therefore their 
size and shape resemble the former considerably. The substance 
of all the casts so far mentioned is the same, the difference in 
appearance being given by the outer adhering formations. Con- 
glomerations of variously sized, sometimes large, fatty globules, 
without well marked contours, showing their original substance, 
! can not be classed as true casts. 

Fatty casts contain a varying number of small, glistening fat- 
j globules and -granules, which give to the cast a high refraction, 
j the cast being either completely or partially filled with them. As 
| they are secondary products only, it follows that, even when they 
j are present in small numbers, the diagnosis of a chronic process is 
justified ; the more so, the more completely they are formed. The 
commencement of their formation can frequently be seen in both 



114 



-rziy^zi _;^::r^ ^vi ::^ :-:>"*:* 



epM&elM and grannlax easts, the grannies beeonwng more glisten- 
ing and highly ire&adtive, and finally changing to globules. Wh 
the easts axe present in large numbers, they always denote a pxo- 

-_ :..-". :."""" .".-_-:_.-:'"- i : :i- lr.ii.r- -.- : ::.l ". in :ir i-i^r 
in in r 7 





4 -. 



pg0pp" 







6. Wfflrjr CW* Case .Pig. 50). — Waxy eastos axe diffiexent 

inn n.i Ht it: in i;;.i.i_- /,— :i T - .mi 

by wavy, tftnted eontonxs, a high xefraefting power, a 
yellowish color, and a high degree of britttleness. They 
greatly in size, and axe always nsore ox less isxegnlax, on 

: iir_: i'r.;::i:.v ;::\Vr-_ . :.- : i> > _.--.:..-- :lri: 



TUBULAR CASTS 



115 



fluted appearance is extremely pronounced, and they may resemble 
regular cork-screw windings. 

When all these characteristics are present the diagnosis of a 
waxy cast is plain, and such a cast will never appear in acute 




Fig. 50. Waxy Casts (X 500). 

C, casts from convoluted tubules ; N, from narrow tubules 
collecting tubules. 



S, from straight 



inflammations, but only in chronic processes, which, if the casts 
are at afl numerous, are always intense. They invariably signify 
waxy degeneration of the kidney. Sometimes hyaline casts exhibit 
spiral windings, and may somewhat resemble waxy casts. These 
spiral windings are probably due to their having originated in the 
spiral portion of the ascending branch of the loop -tubule, and 



116 



URIXAET ANALYSIS AXD DIAGNOSIS 



have no special significance. Such hyaline casts never have the 
same high refraction as the waxy casts, and a little care is suffi- 
cient to differentiate them from each other. 

Pure waxy casts may be found studded with different forma- 
tions, which, of course, will not change the character of the cast. 




Mixed Casts | X 500). 

At times they are of extremely large size, and may then be almost 
entirely broken in different portions. 

7. Mixed Casts (see Fig. 51). — In a large number of cases. 
when casts are present, these casts will not appear in their tru 
form, but may be more or less mixed. Any two. three, or fo 
varieties maybe so intermingled as to be difficult of differentiation 
The more common of these forms will be found in Fig. 51. 



TUBULAR CASTS 117 

Iii the first row, the first east shows an epithelial- granular- 
fatty variety, with the epithelia perfectly intact, while the other 

I 1 casts partly show how the epithelia break down and become disin- 

II tegrated into granules and fat-granules and -globules, partly the 
change of granular into fatty casts. The disintegration of the 

i epithelia, in the manner here depicted, is frequently seen in sub- 
acute inflammations. The change of granular casts into the fatty 
kind is seen in chronic processes. 

In the second row, combinations of waxy casts are shown, the 
first being a fatty- waxy ; the second, a granular -fatty -waxy, while 
the third and fourth are blood -waxy casts. The first cast in the 
third row is an epithelial-blood cast ; the second a blood-epithelial - 
granular -fatty cast, and the third an epithelial -granular -fatty- 
waxy cast. The diagnosis of a case does not, of course, become 
altered by these combinations. 

Other Casts. — Besides these six varieties of casts, the mucus- 
casts or cylindroids, previously described, are occasionally placed 
among the true casts ; that they do not have any special significance 

I has already been stated. They may contain a varying number of 
fat -globules, but their striated, irregular appearance is sufficient 
to clear up the diagnosis. 

Again, a separate variety of casts is described as being de- 
rived from the seminal tubules. These casts are said to resemble 
hyaline casts, but to differ from them in their larger size, greater 
breadth, and greater irregularity. They are, however, nothing 
but cylindroids, and, as such, have no special significance. 

II. FALSE OB PSEUDO CASTS 

False or pseudo casts are not infrequently found in the urine, 
and have no connection whatever with diseases of the kidney. 
These formations are mostly conglomerations ' of different sub- 
stances upon mucus -threads or -casts, or accidental formations in 
the shape of casts. When true casts, especially of the hyaline 
variety, are present, together with an abundance of urates, the 
\ latter may undoubtedly be found upon the casts to such a degree 
I as to render a diagnosis of the original cast doubtful. 

Urate Casts (see Fig. 52). — Among these formations, con- 

j glomerations of urates, sometimes called uric acid casts — although 

uric acid, as such, rarely enters into their structure — as well as 

casts of urate of sodium, are not infrequently found. The for- 



118 



URINARY ANALYSIS AND DIAGNOSIS 



mer, consisting of conglomerations of urate of ammonium, are 
described as occurring only in infants, and forming in them 
small, reddish brown masses, apparent to the naked eye ; but 
they are also seen in adults, although very rarely. Formations 
of urate of sodium, resembling casts, may at times be mis- 







Fig. 52. Casts of Urate of Ammonium and Urate of Sodium (X 500) 



taken for granular casts ; but they have the characteristic yel- 
lowish brown color of urate of sodium, and show no outlines in 
many cases. When the masses of urate of sodium are not heavy, 
mucus -threads or -strings can be distinctly seen underlying them. 
Besides these, we may also see such formations composed of 
urate of sodium in transition to urate of ammonium. When 
this transition has not advanced far, granules as well as small 
globules and dumb-bells are plainly visible ; but if, on the other 
hand, the granules have all become changed to globules and 
dumb-bells, care should be taken not to mistake them for dis- 
integrated blood casts. Here, too, the absence of a contour, as 



TUBULAR CASTS 



119 



well as the color of the urates, will be sufficient for a diagnosis. 

Among the other pseudo casts, the more common are bac- 
terial, pus, fat, and fibrin casts (see Fig. 53). 

Bacterial Casts. — Bacterial casts are frequent occurrences, 
especially when the urine has been allowed to stand in a warm 




Fig. 53. False or Pseudo Casts (X 500). 
B, bacterial casts ; P, pus casts ; Ft, fat cast ; F, fibrin casts. 



room for twelve hours or more, so that a large number of 
bacteria have developed. They undoubtedly resemble granular 
casts so much as to sometimes require a sharp focusing for their 
differentiation. The} 7 may vary considerably in size, but their 
outlines are pale and more or less irregular, and they are composed 



120 URINARY ANALYSIS AND DIAGNOSIS 

of masses of micrococci, not of granules. They have no signifi- 
eanee whatever, except when found in perfectly fresh urine 
an aid fee liagnosis, where they are most likely to be seen in 
severe innammatory or suppurative processes As a rule, the 
micrococci become leposited upon mucus -threads. In order to 
- j up their diagnosis, it may. in rare ^ases be necessary to 
iroj m fcwc : some strong mineral acid or alkali 
which they will be seen to have a great resistance 

•■-• — Pus ;asts— fch at is stst-like Mmglomerations of 
pus -corpuscles, usually upon mucus — are found in some ases 
The pus - corpuscles may be massed together, with no outlines 
visible :_ they are more loosely arranged, and may contain a 
nnm'r: :: small fat - globules . Pus -corpuscles may. of 
be found in small numbers upon different true easts, such is 
hyaline or epithelial, but such formations can not be classed 
as pus jasts 

Fat easts. — Pseudo fa: casts an but have been found 

few eases of so-called lipuria. Th sist of large fat- 

globules, having a very high refraction, an sionally con- 

taining margaric acid needle- Again, a number of extras 
fat -globules upon mucus-threads have been seen ; but these have 
a yellowish color, and can easily be differentiated. 

fflbr sfe. — Lastly, fibrin casts may be found in ses : 

haemorrhage. They may be of large size, have irregular, m re 
or less sharply defined contours, and a yellowish 01 yellowish 

wn color. They consist of small, wavy, irregular fibers, and 
our without the presen e f characteristic strings or 
bands of fibrin. In cases of hemorrhagic parenchymatous ne- 
phritis, true bloc I sts are always issc iated with them. 

Besides haemoglobin, which may occur in the form of casts. 
two other varieties of pseudo casts have been described, namely, 
I :ent and eholeste rin ists Peyei has seen >ne specimen 
of each of these, but thev are the rarest formations in urine. 






Chapter XII 
MICRO-ORGANISMS AND ANIMAL PARASITES 

I. MICRO-ORGANISMS, OR FUNGI 

Perfectly fresh, absolutely normal urine never contains micro- 
organisms or bacteria, though they may develop in a short time 
after the urine is voided. In diseased conditions, on the other 
hand, bacteria may be present in large numbers when voided ; 
such urine is always more or less turbid. Sometimes a number 
of micro-organisms may be found in otherwise normal urine, 
especially in that of the female from the vagina. In cases where 
so large a number of bacteria is voided with the urine as to 
render it turbid, the designation Bacteriuria may be used. 

The development of bacteria in urine may be slow or rapid, 
depending partly upon the reaction and partly upon the tem- 
perature. In an alkaline urine they develop rapidly, and in a 
warm temperature may be found in large numbers one or two 
hours after the urine is voided. Bacteria present when the 
urine is passed are derived partly from the blood and partly 
from the different portions of the genito- urinary tract. 

Micro-organisms seen in urine may be divided into non- 
pathogenic and pathogenic. The former may belong either to 
the class of mould-fungi, to that of yeast -fungi, or to that of 
fission -fungi, while the latter belong to the class of fission- 
fungi. 

Non-pathogenic Micro-organisms. — 1. Mould- fungi . — Mould- 
fungi or hyp homy cetce found in urine are either oidium, penicil- 
lium glaucum, or one of the aspergilli, the latter being compara- 
tively rare. These fungi will be seen 011I3- in acid urine, or urine 
which was originally acid, even though it has become alkaline. 

The most common of the hyphomycetae is the oidium lactis, 
composed of conidia and mycelia (see Fig. 54). It easily de- 
velops in small numbers in urine of a highly acid reaction, and 
can be seen with the naked eye, in the form of whitish masses, only 
when present in large amount. Such urines contain a varying 

(121) 



122 URINARY ANALYSIS AXD DIAGNOSIS 

number of small globules, in which frequently a central so-called 
vacuole is observed, together with threads of mycelia, either 
narrow and short, or quite large and branching. The globules 
are the spores or conidia, and care must be taken not to mistake 




Fig. 54. Oidium Lactis (X 500). 

them for red blood -corpuscles or even fat- globules, which might 
easily be done. They vary in size, and can generally be dis- 
tinguished by the central vacuole. The threads are the mycelia, 
which are, as a rule, coarsely granular and segmented, and con- 
tain a number of spores. 

Besides the oidium lactis, both the penicillium glaucum and 
different varieties of aspergilli may be found in the urine, the 
former being quite common (see Fig. 55). The diagnosis of 
penicillium or aspergillus can be made only by the characteristic 
division of the hyphee. In penicillium glaucum, the most common 
mould -fungus, the hyphse divide and subdivide into thread- 
like formations, — the basidia and sterigmata, — the ends of which 
latter are surmounted by a number of spores or conidia. In the 
aspergilli no division takes place, but the hypha terminates in a 
spherical or club-shaped vesicle, from the periphery of which a 
number of short flask -like formations, — the sterigmata — are 



2IICR.0-0RGAXISMS AXD ANIMAL PARASITES 



123 



visible, each of which contains a single spore upon its upper 
end. 

2. Yeast-fungi (see Fig. 56). — The yeast-fungi or saccha- 
romycetcB are found in acid urine, and are most frequently seen in 




Fig. 55. Penicillium Glaucum and Aspergilli (X 500). 

The upper half of the drawing shows the penicillium glaucum, the lower half different 
varieties of aspergilli found in urine. 

those containing sugar, where they may be present in large num- 

| bers. They consist of variously sized globules or cells, the 

larger of which contain a smaller globule or nucleus. They 

never form mycelia, but multiply by sprouting or budding. The 



124 URINARY AX ALT SIS AND DIAGNOSIS 

globules have an oval or round shape, lie either singly, in twos, 
or in groups of different sizes, and are frequently beaded. In the 
larger globules, the process of budding can be plainly seen. The 
smaller globule, or daughter -cell, sprouts out from the larger or 
mother- cell, becomes an independent formation, grows, and, in its 
turn, forms a mother-cell. These globules may undoubtedly 




Fig. 56. Saccharomycet^ (X 500). 

resemble blood -corpuscles, but their irregular size and shape, 
together with the presence of the nucleus, will be sufficient to 
differentiate them. 

3. Fission-fungi (see Fig. 57). — The fission-fungi or schizo- 
mycetcB are rarely seen in highly acid urine, but frequently in 
urine which is becoming alkaline or has already undergone an 
alkaline change, and is showing putrefaction. When they are 
present in large numbers the urine is always cloudy, and both 
cocci and bacilli may be found. Of the former, the most 
numerous are large cocci, lying either irregularly or in small 
chain-form, — the micrococcus urece. This coccus, to a great degree, 
causes ammonical decomposition of the urine, the urea being 
transformed by it into carbonate of ammonium. In urines con- 
taining pus -corpuscles in large numbers, both staphylococci and 
streptococci pyogenes, the former being small cocci grouped in 
variously sized, irregular bunches, and the latter in longer or 
shorter chains, will also be seen. Besides these, the so-called 
zooglcea groups of cocci — cocci arranged in more or less regular 






MICRO- ORGANISMS AND ANIMAL PARASITES 125 

masses— enveloped in a colorless, gelatinous capsule, may also be 
found, as well as large cocci, the sarcince, which are united into 
packets resembling corded bales of cotton, and are usually smaller 
than the sarcinae found in sputa. Staphylococci and strepto- 
cocci pyogenes are pathogenic, and may be found in any inflam- 
matory condition. 

Bacilli are usually present in varying numbers with the cocci, 
and are of different sizes, some of the small ones occasionally 
lying in twos, being formerly called bacterium termo, one of the 
varieties of putrefactive bacilli which cause ammoniacal decompo- 
sition of urine. Others, among them the bacillus, or bacterium 
urece, are larger, and there are still others larger than the latter, 
among which the bacillus subtilis, or hay bacillus, is common. 







.■'/'■:/ 







Fig. 57. Schizomycet^ (X 500;. 
B, bacilli ; St, streptococci ; Sa, staphylococci ; L, leptothrix ; MU, micrococcus urese ; 
Z, zooglcea ; S, sarcinae. 

These bacilli are found to have a varying amount of motion, 
some being very active, others only slightly movable, and some 
without motion. 

Besides the single bacilli, the urine not infrequently contains 
threads, composed of individual rods, — the leptothrix threads, — 
which may be quite abundant. There are cases of chronic 
cystitis, in which the urine, when voided, contains leptothrix 
threads in large numbers, and in which the cvstitis seems to be 



126 URINARY ANALYSIS AND DIAGNOSIS 

caused by the leptothrix ; these threads may lie upon as well as 
between the epithelia. In such cases whitish masses of small 
size are found in the freshly voided, cloudy urine, and when 
examined under the microscope are seen to consist of conglom- 
erations of bladder epithelia with many leptothrix threads . 
Cases of this kind may last for many years, and frequently recur 
in spite of all local treatment ; such a case might be termed 
Mycosis leptothricia cystidis. 

Pathogenic Schizomycet^:. — Among the pathogenic bac- 
teria, the most important are undoubtedly the gonococci and 
tubercle bacilli, which are not infrequently found in urine, and 
for which careful search must, when necessary, be made. For 
the detection of these, it will always be necessary to color the 
specimens, and the mode of procedure is the following : Select 
the thickest portion of the urinary sediment or the threads, if 
any are present, as will be the case in every chronic gonorrhoea, 
and by means of a sterilized needle spread carefully over per- 
fectly clean cover- glasses, taking never less than four, but pref- 
erably six or more. Allow the glasses to dry thoroughly, and 
draw them through the flame of an alcohol lamp or a Bunsen 
burner in a moderately quick manner, specimen side upward, 
three times, partly to fix the specimen upon the cover -glass, and 
partly to coagulate the albuminous substances present. Then 
color the specimen with an aniline color, either fuchsine, methy- 
lene blue, or gentian violet. 

Gonococci. — In searching for gonococci in the urine, the cover- 
glasses are best colored, for a few seconds to one or two 
minutes, either with a plain watery fuchsine solution, made by 
taking one part of a concentrated alcoholic fuchsine solution 
(one part of fuchsine in substance to four or five of absolute 
alcohol) to eight, ten, or twelve parts of distilled water ; or with 
a methylene blue solution — twelve or fifteen drops of a conceu 
trated alcoholic solution to one ounce of water, to which one 
drop of a 5 per cent caustic potash solution has been added. 
Either one of these solutions, if carefully made, will keep a 
long time, and is always ready for use. 

After having passed the cover -glasses through the flame, as 
just described, a small amount of the coloring solution is 
dropped upon the specimen and allowed to remain for from a 
few seconds to a minute or two, the former being sufficient when 
fuchsine is used, the latter being necessary when methylene blue 



MICRO-ORGANISUS AND ANIMAL PARASITES 



12' 



is employed. After coloring, the cover -glass is rinsed in water, 
the lower surface dried, and the specimen either at once mounted 
upon a slide and examined in water, or dried and mounted in a 
drop of Canada balsam. 

Although the gonococci can be seen with a power of 500 
diameters, it will always be better to use a power of at least 
700 or 800 diameters and an Abbe condensor. In specimens so 
prepared, the gonococci, as well as the nuclei of the pus -cor- 
puscles and epithelia, are colored. The pus -corpuscles will be 
seen to contain one or more nuclei. 

In cases of acute gonorrhoea (see Fig. 58) the gonococci, or 




far JJr **- ^ MhJzL 



Fig. 58. Acute Gonorrhcea (X 700). 
O, groups of gonococci ; G P, pus-corpuscle, containing gonococci ; M S, mucus-thread. 

micrococci gonorrhoeae, are found in large numbers in the urine, 
not as numerous as in the gonorrhceal pus taken directly from 
the orifice of the urethra, but still very abundant. They are 
seen both in the pus -corpuscles and lying free in variously sized 
groups. The pus -corpuscles are numerous and mucus -threads in 
small numbers are always present. Urethral epithelia are also 
usually found, and may contain groups of gonococci. 

Gonococci were first discovered by Neisser in the year 1879, 
and cultivated by Bumm in 1885. They are, as a rule, found 
in twos, either singly or in groups, with the adjacent surfaces 



128 URINARY ANALYSIS AND DIAGNOSIS 

flattened and separated by a colorless interspace, giving the 
so-called biscuit shape. The more or less regular groups of 
diplococci are found either entirely within the pus -corpuscles or 
epithelia, or lying entirely free, but never half-way within and 
half-way free, though large groups, completely filling the pus- 
corpuscles, may slightly overlap the periphery. Again, no mat- 
ter how completely the pus -corpuscles are filled with them, the 
nucleus or nuclei will always remain free, though here, again, 
individual cocci may be found upon the periphery of the nucleus. 
These features, though perhaps not absolutely characteristic, are 
sufficiently so for all practical purposes. 

If any doubt remains about their character, a few specimens 
should be colored with a gentian violet solution, either a 1 pei 
cent aqueous solution (gentian violet 1 part, distilled water 99 
parts), or an aniline water solution, made by adding 5 parts of 
a concentrated alcoholic solution to 100 parts of aniline water 
(aniline oil 1 part, distilled water 20 parts, and filter) for a few 
minutes and subjected to Gram's solution (pure iodine 1 part, 
iodide of potash 2 parts, and distilled water 300 parts) for one 
or two minutes. The specimens are now washed in alcohol, then 
rinsed in water and recolored with a 1 or 2 per cent vesuvin 
solution (vesuvin 1 or 2 parts, distilled water 99 or 98 parts) 
for a few minutes, again rinsed in water, and either examined 
in water or dried and mounted in Canada balsam. 

When subjected to this method, the gonococci will have lost 
their original violet stain and have taken up the vesuvin, being, 
therefore, colored brown. This method at once differentiates them 
from the staphylococci, which retain their violet color. If all the 
features enumerated, especially their characteristic grouping 
within the pus-corpuscles, and the loss of their violet color by the 
last-named method, are present, no doubt whatever will exist as to 
the character of the cocci. 

In acute cases of gonorrhoea, the search for gonococci is very 
easy ; but this becomes a more difficult matter in the chronic 
cases, where only a small number of gleet- threads are found in the 
urine. Frequently it is of the utmost importance to determine 
the presence or absence of gonococci in such cases, and the gleet- 
threads are subjected to the methods just described, and care- 
fully examined. In this work it is never advisable to depend 
upon a power of 500 diameters, but higher powers, even a homo- 
geneous immersion lens, should be used, and a large number of 



MICEO- ORGANISMS AND ANIMAL PARASITES 



129 



specimens carefully examined. The features found in such a 
gleet- thread, containing gonococci, are shown in Fig. 59. 

Pus -corpuscles are never so abundant in these cases as in the 
acute, and may even be quite scanty, but mucus -threads as well as 
corpuscles are numerous ; epithelia from the urethra, and usually 
from the prostate gland, will also be seen. The gonococci are 







Fig. 59. Chronic Gonorkhcea (X 700). 

OP, pus-corpuscles containing gonococci ; GE, epithelium from the prostate gland contain- 
ing gonococci ; St, pus-corpuscles, containing staphylococci pyogenes ; Sr, streptococci pyogenes ; 
MU, micrococcus ureae ; MS, mucus-threads ; MP, mucus-corpuscle. 

always found in smaller numbers, but only singly or in small 
groups, and the cocci seen should never be diagnosed as such, 
unless some are found within the pus -corpuscles. Besides gono- 
cocci , such threads will always contain irregular groups of staphy- 
lococci ; these may be either free or in groups, lying partly 
within pus -corpuscles and partly outside. In some cases, strepto- 
cocci, usually in rather small chains, are also present, as well as 
the micrococcus ureae in chains or irregular small groups. 

Other Cocci. — Besides gonococci, other pyogenic cocci, both 
staphylococci pyogenes and streptococci pyogenes, are found in 
urine, but as may be expected, only wherever there are large num- 
bers of pus-corpuscles ; they, therefore, have little practical sig- 
nificance. The staphylococci are the staphylococcus pyogenes 
aureus, albus, and citreus, which can only be differentiated by 



130 V BINARY ANALYSIS AND DIAGNOSIS 

culture methods. Besides the streptococcus pyogenes, a strepto- 
coccus, which can not be distinguished from it, but has been 
described by Fehleisen as being the cause of erysipelas, may be 
found in all cases of erysipelas in which a nephritis is at the 
same time present. Micrococci have also been seen in the urine in 
septic processes, as well as in endocarditis. 

Tubercle bacilli. — The presence of tubercle bacilli in mod- 
erate numbers in the urine is always a symptom of tuberculosis 
somewhere in the genito- urinary tract. Its exact location can 
easily be determined by the characteristic epithelia. As a rule, 
they will be found in larger numbers only when an ulceration has 
taken place ; and whenever the diagnosis of an ulceration can be 
made from the different features found in the urine, together with 
an impaired or broken down constitution, it will be best to 
examine for tubercle bacilli, even though distinct clinical symp- 
toms of a tubercular process have not as yet developed. 

The search for tubercle bacilli in the urine is by no means an 
easy one, and many drops may have to be examined before 
arriving at a definite conclusion.. The appearance of the urine 
is no criterion, since bacilli may be present in small numbers 
in rather clear urine, though as a rule, it will be more or less 
turbid. They can be found in either an acid, neutral, or alkaline 
urine, though a large number of salts renders their detection still 
more difficult. The thickest portion of the sediment only should 
be used for the preparation of cover-glass specimens, and here the 
use of the centrifuge offers an undoubted advantage, the bacilli 
being more easily discovered in a centrifuged than in a non-cen- 
trifuged urine, since the centrifuge throws down all bacilli in 
larger numbers than is the case with urine which has been allowed 
to settle for a number of hours. 

The methods employed for detecting tubercle bacilli are 
numerous ; but the best are the Koch-Ehrlich-Weigert aniline 
water and the Ziehl-Neelsen carbolic acid water methods. Whether 
fuchsine or gentian violet is used with the former method is per- 
fectly immaterial. An aniline water fuchsine solution is made by 
adding enough of a concentrated alcoholic fuchsine solution to 
aniline water until saturation takes place ; that is, until a distinct 
film appears at the top of the solution ; this will usually be one 
part of the alcoholic solution to six, eight, or even ten parts of 
aniline water. The aniline water is prepared by thoroughly mix- 
ing one part of aniline oil with 20 parts of distilled water, 



MICRO-ORGANISMS AND ANIMAL PARASITES 131 

and filtering through a double layer of filter- paper. This solution 
must be perfectly clear. The cover- glasses, which, when dried, 
have been passed through the flame, are now dropped upon the 
solution, specimen side downward, so as to float, if possible, and 
allowed to remain in it for twelve hours, if kept at the tempera- 
ture of the room, or forty minutes if the solution is kept warm. 
It is not advisable to heat the cover- glasses over the flame for a 
few minutes after having dropped the coloring solution upon them, 
as such specimens are usually not as clear as they should be. 

It has been shown by Koch that while tubercle bacilli take 
on the coloring matter slowly, they are then not readily decolor- 
ized, in contradistinction to other bacteria, which will quickly lose 
their color when subjected to the action of strong acids. The 
cover- glasses, after being colored, are, therefore, placed into a 
strong acid solution, preferably a 25 per cent nitric acid, for a 
few seconds or half a minute, and are then thoroughly washed in 
a 60 per cent solution of alcohol until all color has disappeared, 
rinsed in absolute alcohol and in water, and may either be ex- 
amined at once, or, better, are recolored with methylene blue, 
again rinsed in water and examined in water or Canada balsam. 
The tubercle bacilli, if any are present, will now be seen in the 
form of red rods, while all other features in the specimen are 
colored blue. Instead of aniline fuchsine, aniline gentian violet 
can be used, and vesuvin employed as a recoloring agent. Muri- 
atic or sulphuric acid may be used instead of nitric acid. 

A specimen of tuberculosis of the kidney, colored in this 
manner, is shown in Fig. 60. The features which can easily be 
recognized are tubercle bacilli in moderate numbers, pus -cor- 
puscles, epithelia from the convoluted tubules of the kidney, 
epithelia from the pelvis of the kidney, mucus -threads, mucus- 
corpuscles, and various cocci. 

Although specimens prepared with an aniline water solution 

! give excellent results, there is one objection to this method, which 

j is that the solution does not keep, and has to be prepared fresh 

I every week. Many bacteriologists, therefore, prefer to use Ziehl- 

1 Neelsen's carbolic acid fuchsine method. The solution is pre- 

j pared by taking 90 parts of a 5 per cent carbolic acid solution, 10 

parts of alcohol, and 1 part of fuchsine in substance. This is 

undoubtedly the simpler method, and gives good results as long as 

the solution is not too old. With it the specimens need not be 

colored longer than one or two hours, when kept at the tempera- 



132 



URINARY ANALYSIS AND DIAGNOSIS 



ture of the room, or twenty minutes when dropped in a warm 
solution. The decolorizing and recoloring processes are exactly 
the same as with the Koch-Ehrlich-Weigert method. 

Since examination for tubercle bacilli in urine is not an easy 
matter, it is invariably best to use those methods which will yield 
uniformly good results, and not to hasten the process of coloring. 
With the two methods just described, the tubercle bacilli can 




Fig. 60. Tubekculosis of the Kidney (X 650). 

TB, tubercle bacilli ; PC, pus-corpuscle ; CE, epithelium from convoluted tubules of kid- 
ney ; PE, epithelium from pelvis of kidney ; MS, mucus-threads ; MC, mucus-corpuscle. 

always be detected if present, though they may be very scanty, 
and found only after a long and patient search. 

Typhoid bacilli. — Among the other pathogenic bacilli found in 
urine, the typhoid bacilli have been discovered in large numbers 
in cases of typhoid fever, though never at the commencement I 
of the disease, and they are not, therefore, of much practical j 
value for the diagnosis. Poniklo, in the year 1892, was the first 
to call attention to the presence of typhoid bacilli in the urine, and \ 
since then the bacilli have been found by different observers. In 
most cases described, the evidences of a more or less pronounced 
nephritis or of a haemorrhage were also present. The bacilli may 
persist in the urine for weeks and even months, and may be 
extreme^ abundant. 

Bacterium coli commune. — The bacterium coli commune is 
not infrequently present in urine, especially in pronounced in- 



MICRO-ORGANISMS AND ANIMAL PARASITES 



133 



flammations, such as severe cystitis ; it may be found in large 
numbers, and is mentioned by some writers as a common cause 
of cystitis. In the year 1895, Plivym and Laag described it as 
the sole cause of a urethritis which gave all the symptoms of a 
gonorrhceal infection, in which gonococci were entirely absent, 
but the bacterium coli commune was found in large numbers, 
lying mostly within the pus -corpuscles and epithelia. 

Other bacilli have also been described as being present in 
various diseases of the genito-urinary tract, but they are of no 
diagnostic value. 

Actinomyces. — The fungus known as actinomyces (see Fig. 61), 
is of rare occurrence in- the urine, but is undoubtedly found in 
actinomycosis of the internal organs, where the disease affects the 
genito-urinary tract. The classification of this fungus has long 




Fig. 61. Actinomyces (X 500). 

been undecided, though later researches place it among the fission- 
fungi. 

The fungus consists of variously sized conglomerations of 
highly refractive, irregular, club-shaped masses. The club-shaped, 
cylindrical, or pear-shaped masses terminate toward the center in 
a point or fibrilla, which loses itself in a mass of granules, 
amidst other similar fibrillae. The individual club-shaped elements 
greatly vary in length, but all terminate in the center. 

The urine from which the accompanying drawing was made 



134 



UEIXAET ANALYSIS AXD DIAGNOSIS 



was turbid when passed, and gave all the maeroseopical evi- 
dences of a ehronie cystitis. It contained a few small granular 
masses which proved to be actinomyces. The features present 
under the microscope were numerous, and conclusively showed 
a chronic ulcerative process in the bladder ; there were pus- 
corpuscles in large numbers : epithelia from the bladder, espe- 
cially cuboidal and columnar ; numerous connective -tissue shreds ; 
f at - granules and -globules ; large zooglcea masses ; mucus- 
threads and -corpuscles, and the actinomyces fungus, which was 
perfectly characteristic, so that the diagnosis of a chronic 
ulceration of the bladder, due to actinomyces, could easily be 
made. The reaction of the urine was alkaline. 

II . ANIMAL PARASITES OB ENTOZOA 

Trichomonas Vaginalis (see Fig. 62). — Of all the animal 
parasites, the most common is the trichomonas vaginalis, which 
belongs to the class of infusoria. It occurs in the urine of 




Fig. 62. Trichomonas Vaginalis 



3 'A . 



females, being a frequent but perfectly harmless inhabitant of 
the mucosa of the vagina in cases of leucorrhcea. Although 
it has no pathological significance, its occurrence and shapes 
must be known, since it otherwise might be mistaken for 
different formations, especially when small. 



MICRO-ORGANISMS AND ANIMAL PARASITES 



135 



Trichomonas is of an oval or somewhat irregular form, and 
usually has a tail -like extremity. This extremity, mostly of 
the same size as the body or a little longer, may occasionally 
be three or four times that size, of considerable thickness, and 
striated. It may, however, be nothing but a small filament 




Fig. 63. Portions op Eohinococcus (X 400). 

like a flagellnm. In the interior of the body one, two, or more 
small formations, similar to nuclei, may be seen. In many cases 
one or more cilia are given off from one extremity or side. 

Echinococci (see Fig. 63). — These entozoa, although rare, do 
occasionally occur in the urine, and may either have developed 
directly in the urinary organs, or have ruptured from some 
neighboring organ. The characteristic parts of the echinococci, 
found in the urine, are the hooklets as well as portions of the 
membrane ; scolices may also be found. 

The echinococci cysts, as such, will never be seen in the 
urine, and in a suspected case it may become quite difficult to 
find the characteristic portions. The scolices are small, usually 
round, and supplied with a wreath of hooklefs. The individual 
hooklets do not vary in size to a great degree, and their shapes, 
although differing somewhat, are more or less identical. Parts 
of the membrane which have a concentric striation may at 



136 



UEINAEY ANALYSIS AND DIAGNOSIS 



times be present. In the specimen from which the illustration 
was taken, the different portions here shown could only be 
found after patient search, but were characteristic 

In all cases in which parts of the echinococci are found in 
the urine, evidences of a haemorrhage or an ulceration, or both, 
will be present. As a rule, red blood -corpuscles are numerous, 
together with epithelia and connective -tissue shreds from the 
organ in which the cysts are located. Pus -corpuscles are usu- 
ally abundant. When the echinococci have directly developed 
in the urinary organs, the kidney is the general location, and 
epithelia from both the convoluted and straight collecting tubules 
are present. 

Distoma Haematobium (see Fig. 64). — The parasite, di stoma 




Fig. 64. Ova of Distoma Haematobium (x 600). 



hmmatobium, or Billiarzia hcematobia, so called from Bilharz. 
who first described it, has probably never been found in the 
urine, but its eggs do occur in some cases. It is common 
in hot climates, especially in Egypt, and is found in the 
portal vein and its branches, the splenic and mesenteric 
veins, as well as in the venous plexuses of the rectum and 
urinary bladder. 



MICRO-ORGANISMS AND ANIMAL PARASITES 



137 



In our climate distoma haematobium is rarely found, but 
does occur. A case of this kind was recently described by 
Brooks and ^ondern, who found the eggs in the urine in con- 
siderable numbers. The illustration was taken from this urine, 
and in every drop examined a dozen or more of the ova were 




Fig. 65. Filaria Sanguinis Hominis (X COO). 

present. They have an oval or flask -like shape, are large and 
taper considerably at one extremity, the other being rounded. 
They consist of a moderately thick, highly refractive capsule, 
are coarsely granular, and contain quite a number of small, 
roundish, granular bodies within a membranous formation. 

When these ova are found in the urine, blood-corpuscles, pus- 
corpuscles, and epithelia, usually from the bladder, are seen, show- 



138 UBIXAUT ANALYSIS AND DIAGNOSIS 

ing a haemorrhage or inflammation of the bladder. In most eases 
fat-globules and -grannies are also present in considerable num- 
bers. The parasites may invade any portion of the urinary tract, 
especially the ureters and pelves. 

Filaria Sanguinis H&mrmh (see Fig. 65). — This parasite is 
also of rare occurrence in our climate, but common in other 
climates, as in the West India Islands. Egypt. China, and Japan. 
It seems to be transferred to human beings through mosquito _ 
bites, and may be extremely abundant in the blood ; in urine it 
may be found in varying numbers in such eases. It consists of a 
cylindrically shaped body, a short, rounded head, and a long, 
thread-like, pointed tail. It is granular and frequently striated. 

When the parasite appears in the urine, it may either cause 
severe hematuria or 'the condition known as ehyluria, or more 
frequently both. It is claimed that it may be present in perfectly 
clear urine, but this must be very rare, since, as a rule, the urine 
presents a milky appearance when voided, and upon examination 
is found to contain a large amount of fat. in the form of small 
globules and granules, as well as the evidence of a more or less 
pronounced haemorrhage. Pus -corpuscles, as well as different 
epithelia, will usually be present in small numbers. 

When such a milky urine, denoting ehyluria. is examined, 
filaria must always be looked for, since the parasite is almost 
invariably the cause of this condition. It may be present in 
large numbers in the urine, so that there will be no difficulty in 
finding it ; but on the other hand, it may be scanty. In examin- 
ing for filaria, it is advisable to take the first urine voided in the 
morning, since it is a well known fact that the parasite is active 
at night, or rather during the resting hours of the patient, and 
can then be found in large numbers in the blood, while it is quies- 
cent during the working hours, and can not be found. 

Aa iris Lxmbriemdes (see Fig. 66). — Although in rare in- 
stances only, the round worm, asearis lumdricoides, of such com- 
mon occurrence in the intestinal tract of children, may be found 
in the urine, having passed into the bladder through the urethra. 
Portions of the parasite and a number of ova will then be present 
in the urine. 

The urine from which the illustration was taken gave all the 
features of a severe acute catarrhal cystitis. It contained a 
small number of minute particles, which proved to be the ova ; 
also a part of the body of an asearis. The ova. of a yellowish 



MICRO-ORGANISMS AXD ANIMAL PARASITES 



139 



brown color, are round formations, inclosed in a thin, irregular 
capsule and a somewhat thicker membrane ; the interior is 
coarsely granular and contains a nucleus. The parasite itself is 
of considerable size, has a cylindrical body, a narrower, tail -like 




Fig. 66. Ova and Portion of Ascaris Lumbricoides (X 500). 

extremity, and a head consisting of three papillaeform nodules; 
it is only found in the urine in very rare instances. 

Other Parasites. — Other parasites which may possibly be 
found in the urine are the Strongylus gigas, Oxijuris vermicu- 
laris, and the Cercomonas urinarius. The strongylus gigas 
resembles the ascaris lumbricoides, although it is much larger, 
and its head contains six papillaBform nodules instead of three. 
The oxyuris vermicularis is a small, thread-like formation, and 
the cercomonas urinarius a small infusorium, which consists of 
an oval, granular body, and contains a number of cilia. These 
parasites are extremely rare and of no practical importance. 



Chapter XIII 

EXTRANEOUS MATTERS 

Extraneous matters are common occurrences in urinary sedi- 
ments, and must be well known, as they might frequently lead 
to errors in diagnosis. Their presence in the sediment may be 
due to many causes, such as exposure to air, from which various 
objects may fall into the urine, pouring the urine into bottles 
which are not perfectly clean, the use of salves or dusting pow- 
ders for the genital organs, or admixture of particles from the 




Fig. 67. Cotton-Fibers (X500). 



faeces. Many of these formations are characteristic enough, 
but others may closely resemble various features of normal 
or pathological urine, from which they must be carefully 
differentiated. 

The different fibers of cotton, linen, silk, and wool are fre- 
quently found in the urine. 

Cotton-Fibers (see Fig. 67). — Cotton-fibers are coarse, some- 

(140) 



EXTRANEOUS MATTERS 



141 




Fig. 68. Linen-Fibers (X 500), 



what wavy and twisted. 
They are highly refractive, 
their edges being more com- 
pact than the center. The 
central portion may appear 
slightly folded, and often 
shows irregular markings. 
When the fibers are very 
small, the diagnosis must be 
made from the wavy, com- 
pact appearance. 

Linen -Fibers (see Fig. 
68). — Linen -fibers are va- 
riously sized, sometimes 
broad, and at other times 
narrow. They are composed 
of smaller fibrillae, which, 
although quite refractive, 
are less so than cotton -fibers. 

At different parts of the fiber, irregular transverse breaks 
are seen, which are caused by the process of hatcheling. The 
finest fibrillae will be found broken off in a very irregular manner 

from the surface of the main 
fiber, being either long or 
short, and at times branch- 
ing in different directions. 
Silk-Fibers (see Fig. 69). 

— Silk -fibers are homogene- 
ous, moderately shining ; 
their cut ends are flattened 
by the blades of the scissors, 
and rendered slightly jagged. 
If from woven goods, the 
fibers assume wavy or spiral 
impressions. 

Wool-Fibers (see Fig. 70). 

— Wool -fibers are coarse, 
and have saw-teeth like ser- 
rations along the edges, cor- 
responding to the edge of 

Fig. 69. Silk- Fibers (x 500.) the imbricated scales covering 




142 



UBIXAST ANALYSIS AXB DIAGXOSIS 




Fig. 



WOOL-FIBEJ.; i r 



the cuticle : their strnctnre is 
faintly striated. Hairs of dif- 
ferent animals have different 
forms, and we may observe 
the central medullary canal 
and a varying amount of pig- 
ment. 

Any of these fibers may 
be found dyed in different 
colors, which is sometimes 
quite misleading. 

Rinnan Hairs. — Human 
hairs are also not infrequently 
found in the urine, and may 
be known by the flat epider- 
mal scales, firmly attached to 
each other, which form the 
main mass of the hair, and 

by the varying amount of pigment. 

Feather (see Fig. 71). — Feather may appear in the shape of 

branching formations, which have their origin at the quill, and 

run in different direc- 
tions, or in single barb- 

ules. The quill is striated. 

The barbules are comr jsed 

of different sized links. 

and gradually taper toward 

the ends, which are whip- 
like. 

Scales from Moth (see 

Fig. 72). — Scales from the 

wings. of insects, such as 

moths, may also be found. 

They are more or less deli- 

"cate. serrated plates with a 

stem -like projection, and 

Vary considerably in length 

and breadth. 

s_ ark - Globules se« 

Fig. 73).— Starch-globule 

are frequently seen in the lis. ti. Feathebix^). 







EXTEAXEOUS MATTERS 



143 




Fig 72. Scales from Wings of 
Moth (X 500). 



urine. They are more commonly 
found in the urine of females, 
starch powders being extensively 
used for dusting purposes, but 
individual globules from the un- 
derwear are also seen. They are 
oval or round, highly' refractive, 
and vary greatly in size, with a 
more or less central hilum or 
umbilicus, around which are con- 
centric striatums. The hilum may 
be either round, oval, or irregu- 
lar, at times quite large, at times 
small, and occasionally appearing 
as if split. 

The different varieties of starch, 
although having the same charac- 
teristics, vary in shape as well as 

in size. The three most frequently found in the urine are rice- 
starch, corn -starch, and wheat -starch. Rice -starch always ap- 
pears in the form of oval or oblong, quite regular globules of 

medium size. Corn- 
starch is smaller, ir- 
regular, at times al- 
most hexagonal, and 
contains an irregular 
hilum . Wheat - starch 
consists of large glob- 
ules, as well as of 
small, irregular form- 
ations, in which latter 
the hilum may be en- 
tirely absent, or is 
present only in the 
form of a dot. 

Lycopodium (see 
Fig. 74). — Lycopo- 
dium, somewhat simi- 
lar to starch, and also 
considerably used for 

R, Rice-starch ; C, corn-starch ; W, wheat -starch. dusting purposes, COU- 




144 



URINARY ANALYSIS AND DIAGNOSIS 




Fig. 7i. 



Lycopodium-Globules 
(X 500). 



sists of globular formations of 
different sizes, with a distinct 
shell, and studded with peculiar 
thorny projections. Many glob- 
ules seen in urine are partially 
broken, and in some an irreg- 
ular or triangular division is 
noticeable. 

Cellulose (see Fig. 75). — 
Cellulose occurs in the urine 
in a variety of forms, some- 
times in small, sometimes in 
large masses. It varies consid- 
erably, according to the plant 
or portion of plant from which 
it is derived, and may be brown, 
pale yellow, or practically color- 
less. It may be seen in the 
urine in the form of a framework, sometimes angular, the 
individual cells being connected with each other by the inter- 
cellular substance. In the interior of many, though not in all 
cells, a nucleus, usually somewhat irregular, will be present, and 
both the cells and the nucleus 
are granular. 

Instead of the irregular 
angular cells, perfectly reg- 
ular, either rectangular or 
square cells, with large, reg- 
ular, oblong nuclei, may be 
seen, and these -may also be 
found singly or in masses. 

Cork (see Fig. 76). — A 
common variety of cellulose 
seen in urine is cork. This 
occurs either in single cells 
or smaller conglomerations, 
and has a yellowish brown or 
reddish brown color. The 
individual cells are irregular 
and greatly vary in size. 
They are either perfectly 




EXTRANEOUS MATTERS 



145 




Fig. 76. Cork (X 500). 



homogeneous or contain a small 
number of indistinct granules. 
At times, many of these cells 
will be found closely packed 
together. When the cells are 
thin, they may possibly be mis- 
taken for epidermal scales, but 
their color is always sufficient 
to differentiate them from the 
latter. 

Oil- Globules and Air-Bub- 
bles (see Fig. 77) . — Extraneous 
fat- or oil -globules are of com- 
mon occurrence in urine. They 
may be very large or extremely 
small, and are either perfectly 
round or irregular. They have 
a high refraction, and can fre- 
quently be differentiated by their yellowish color. The smallest 
globules might perhaps be mistaken for fat -globules voided 
with the urine, but are almost invariably associated with the 

larger, more irregular, 
yellowish globules. 

Air -bubbles also vary 
in size to a great degree, 
and may be either round 
or irregular ; they have 
a sharply denned, double 
contour and a blue or 
bluish black refraction. 

Flaws in Glass (see 
Fig. 78).— Flaws in the 
glass, as well as scratches 
in the cover -glass, may 
easily lead to a mistaken 
diagnosis. The flaws are 
irregular in size and shape, 
and frequently resemble 

the wings of a butterfly. 
Fig. 77. Oil-gloeules and Air-bubbles rrn -i o • , , -, 

(x 500) They have a faint blue 

f, fat- or oii-giobuies ; a, air-bubbies. refraction and are usually 




146 



URINARY ANALYSIS AND DIAGNOSIS 



pale. A little care is sufficient to diagnose them, and if their 
identity is not plain, a change of the glass will suffice to note 
their character. 

Rust - particles in both the cover -glasses and slides also 
occur, and are larger or smaller, dark or rust-brown irregular 
masses, which must not be mistaken for coloring matter in the 
urine. The smaller masses somewhat resemble haematoidin crj^s- 
tals, but are always more irregular. 

Vegetable Matter (see Fig. 79). — Vegetable matter of (lif- 
erent forms may be found in the urine as an admixture from 




Fig. 78. Flaws in the Glass (X 500). 



the fasces. Different plants, which remain partially undigested 
and may be passed with the faeces in small masses, will present 
a variety of features. Spiral fibers from the air-vessels of 
plants are quite numerous in such masses. Hairs of plants, as 
well as vegetable -fibers, the latter resembling connective -tissue 
shreds, will be found, besides particles of cellulose. We may 
furthermore see starch- and chiorophyl- globules, masses of 
spores, fat -globules and margaric acid needles. 

Fceces (see Fig. 80). — Normal faeces may occasionally be 
found mixed with urine, and their constituents must be known. 
If they are present, and their accidental admixture can be 






EXTRANEOUS MATTERS 



147 



excluded, the diagnosis of a fistula can be made. Although 
their features vary greatly, depending upon the food, the most 
common with a mixed diet are the following : 

Partly digested muscle -fibers of a yellowish or brown color 




Pig. 79. Vegetable Matter (X 500). 

Sp, spiral fibers from air-vessels of plants ; V, vegetable -fibers ; H, hairs of plants ; 
C, cellulose ; St, starch - globule ; Ch, chlorophyl- globule ; F, fat-globules ; M, margaric 
acid needles ; So, spores. 

are almost constantly seen ; in many the striations will be 
plainly visible, while in others no structure can be made out. 
Connective -tissue shreds from the meat diet, in small numbers, 
are also present. Spiral fibers, hairs of plants, and different 



148 



URINARY ANALYSIS AND DIAGNOSIS 



forms of cellulose are almost constant ingredients, as well as 
starch- and chlorophyl- globules, and fat in the form of globules 
and needles. 

Mucus -threads and mucus -corpuscles are usually found in 




Fig. 80. Normal Fjeces (X 500). 

MF, muscle-fibers ; CT, connective-tissue shreds ; Sp, spiral fiber ; C, cellulose ; H, hair 
of plant ; MS, mucus-thread ; MC, mucus-corpuscle ; E, epithelia ; Ph, triple phosphates ; 
St, starch-globules ; D, debris ; M, mycelium ; S, sarcina ; Sa, saccharomyces ; F, fat-globules 
containing margaric acid needles ; BC, bacilli and cocci. 

normal fasces, as well as different varieties of epithelia. The 
latter are mostly of the flat variety, derived from the mucous 
membrane of the anus, although a few columnar epithelia are 



EXTRANEOUS MATTERS 149 

not rare. Crystals of various kinds, but most commonly triple 
phosphates, may be quite abundant. Different non- pathogenic 
bacteria, such as conidia and mycelia in small numbers (un- 
doubtedly secondary products), saccharomyces, and large numbers 
of bacilli and cocci, may be found. Besides these features 
masses of debris, digested material, in smaller or larger con- 
glomerations, will be seen. 

The extraneous matters here enumerated as occurring in the 
urine are those which are more commonly found ; but other 
features may be seen at one time or another. For instance, 
water -fungi of different varieties, although rare, are known 
to occur in urine. It will, however, be a comparatively easy 
matter to recognize most of the extraneous objects. 



Paet Three 
MICROSCOPICAL URINARY DIAGNOSIS 



Part Three 
MICROSCOPICAL URINARY DIAGNOSIS 



Although it has been customary, in arriving at a correct 
diagnosis of diseases of the gen ito -urinary tract, to consider the 
microscopical examination of the urine as only of secondary 
importance, and, in diagnosing the different inflammations of the 
kidney, to rely solely upon the presence of casts, a perusal of the 
previous pages will show that the microscope is not only of the 
utmost importance in all these affections, but is frequently the 
only means of arriving at correct conclusions as to the nature 
of the case. 

It is a well known fact that in many cases in which a small 
amount of albumin is present in the urine, and in which the 
clinical symptoms seem to point to a nephritis, even if only 
slight, that diagnosis will not be made, because frequent exami- 
nations of the urine fail to reveal any tubular casts, and the 
physician is apt to rest satisfied with the diagnosis of "functional 
albuminuria ; " yet a large number of not infrequently severe 
-cases of nephritis exist which never show casts in the urine. 
In cirrhosis of the kidney, for instance, the presence of casts is 
extremely rare, and when they are present at all, are so scanty, 
in most cases, as to be entirely overlooked. 

On the other hand, many cases of nephritis, often lasting 
for years, will give such ill -defined clinical symptoms that a 
kidney inflammation is rarely thought of ; and the examination 
of the urine, if made at all, is done rapidly, and merely with 
the idea of satisfying oneself that casts are not present. Many 
of these cases will show only a trace of albumin in the com- 
mencement stage, and might not only be greatly benefited, 
but entirely cured, if a proper diagnosis were made soon 
enough. Such a diagnosis can always be made from a micro- 
scopical examination of the urine, even without the presence of 
casts, and the larger number of the mild cases never show casts 
in the urine at any time. 

(153) 



154 



miXJJlT ANALYSIS AND DIAGNOSIS 



The diagnosis ~: an inflammation or other affection of the 
tidneys is nndoubtedly the most important ; but a microscopical 
examination of the urine may also he the only means of positively 
liagnosiiig the natur- : lisease :: the pelvis of the kidney, the 
Madder, and the prostate gland, as well as of clearing np a 
suspected case of inflammation of the seminal vesicles. In the 
female, an inflammation or ulceration of the vagina, the cervix 
nteri, and the mncosa of the nterns can often be positively 
identified from the examination of urine, without the necessity 
of an examination of the patient. It can thus easily be seen 
that the microscope plays an extremely important role in genito- 
urinary affections . either giving the first evidence of a disease, 
or helping to clear up a doubtful diagnosis. 

In the following pages >nly those affections will be ::_:- 
sidered which can be positively diagnosed from a microscopical 
examination of the urine. 



Chapter XIV 

DISEASES OF THE KIDNEY AND PELVIS 

I. INFLAMMATIONS OF THE KIDNEY AND PELVIS 

Classification. — There are probably no diseases in which the 
opinions of pathologists differ so much, and in which the 
nomenclature is so varied, as in inflammations of the kidney, 
— nephritis. The result must necessarily be confusion. Such 
different terms as Bright' s disease, interstitial, desquamative, 
exudative, parenchymatous, and diffuse nephritis are met with, 
and congestion, hyperemia, glomerulitis, pyelo- nephritis, and 
amyloid disease are all looked upon as different affections. 
While some authors use the term Bright' s disease as indicat- 
ing all the different varieties of nephritis, others call diffuse 
nephritis Morbus BHgMii ; others, parenchymatous nephritis; 
and still others, combinations of different varieties. 

One classification* gives no less than seven different varieties 
of Bright's disease: (1) Congestion of the kidney; (2) acute 
parenchymatous nephritis ; (3) chronic parenchymatous nephri- 
tis ; (4) acute diffuse nephritis; (5) chronic diffuse nephritis; 
(6) acute interstitial nephritis ; (7) chronic interstitial nephritis. 
Besides these, this classification gives suppurative nephritis and 
pyelo - nephritis separately. 

Another classification! of Bright's disease is the following : 
(«) Acute nephritis (acute Morbus Brightii), in which acute 
hemorrhagic nephritis and acute glomerulo- nephritis are in- 
cluded; (b) chronic nephritis (chronic Morbus Brightii), which 
is again divided into four varieties — (1) large white kidney 
(inflammatory fatty kidney), (2) large red kidney (chronic 
haemorrhagic nephritis"); (3) secondary cirrhosis of the kidney, 
and (4) contraction of the kidney (cirrhosis, granular atrophy 
of the kidney) . Besides these, this author speaks of interstitial 



* Delafield and Prudden, "A Handbook of Pathological Anatomy and Histology." New 
York, 1885. 

tBirch-Hirsehfeld, "Lehrbueh der Pathologischen Anatomie." Leipzig, 1887. 

(155) 



156 URINARY ANALYSIS AND DIAGNOSIS 

suppurative nephritis (pyelo- nephritis and embolic suppurative 
nephritis), as well as of fatty, calcareous, and amyloid degenera- 
tion of the kidney. 

Without going any further into the different classifications, 
which no two authors give alike, the latest classification* only 
will be mentioned : This simply gives the varieties as acute 
and chronic nephritis, dividing the latter into chronic paren- 
chymatous and chronic interstitial nephritis (cirrhosis, granular 
atrophy of the kidney). 

It is, therefore, not at all surprising that the pathology of 
nephritis is considered to be one of the most complicated chap- 
ters in pathology ; yet it will become perfectly plain, and the 
features found in urine easily explained, if we consider the 
anatomical structure of the kidney, which is that of a compound 
tubular gland, consisting of epithelial and connective tissue ; 
the latter alone carries the blood-vessels, the contents of which, 
the blood, furnishes the material from which the epithelia pro- 
duce the secretions. 

Experiments have frequently been made to show that patho- 
logical conditions of the epithelia can exist independently of 
the underlying connective tissue carrying the blood-vessels. It 
has been asserted that in acute cases of poisoning, such as with 
cantharides and phosphorus, the pathological process is confined 
to the kidney epithelia alone. Other experiments have, how- 
ever, conclusively proved that an independent pathological con- 
dition of the epithelia does not exist. The poison, before it 
reaches the epithelia, must pass the walls of the blood-vessels 
and the connective tissue lying between the epithelia and the 
walls of the blood-vessels, and has an irritating influence upon 
the latter. In this connective tissue, changes are always found, 
though they may be confined to serous transudation, sufficient 
to show that the epithelium can not become diseased primarily 
and independently of the surrounding connective tissue. 

It is, therefore, plain that the classification by Virchow, of 
inflammations into interstitial, that is, confined to the connec- 
tive tissue, and parenchymatous, confined to the epithelia, is not 
strictly correct. Every inflammation is primarily an interstitial 
one, and every parenchymatous inflammation must also at the 
same time be an interstitial one. It is perfectly true, however, 



*Hilbert, in " Bibliothek der gesammten medicinischen Wissenschaften." Vienna, 1898. 



DISEASES OF THE KIDNEY AND PELVIS 157 

that the pathological changes may be more pronounced in the 
epithelia than in the connective tissue ; the latter may not pass 
be3 r ond the stage of serous transudation, while in the former 
coarse granulation, so-called cloud}^ swelling, may occur ; in cases 
of phosphorus poisoning fatty degeneration may be present. 

The character of an inflammation depends to a great degree 
upon the nature of its exudate, which may be either serous, 
fibrinous, or albuminous. In former years inflammations of 
mucous membranes were divided into catarrhal and croupous ; 
in the first a serous or sero- mucous exudate is formed, while in 
the second it is fibrinous in its character. These names, though 
not of great significance, are perhaps preferable to Virchow's 
terms, interstitial, desquamative, and parenchymatous, which, as 
has been shown, can not be carried out. An inflammation in an 
organ composed of connective and epithelial tissue will affect 
all its component parts to a greater or less degree, so that it 
will be diffuse to a certain extent at the outset. The difference 
exists only in the degree in which the different tissues are 
affected. We may, if we wish, speak of an interstitial inflam- 
mation when the pathological changes are more pronounced in 
the connective tissue, and of a parenchymatous inflammation 
when they are more pronounced in the epithelia. 

As every inflammation of the kidney is bound to be more or 
less diffuse in its character, and the term Bright's disease 
conveys no meaning as to the character of the inflammation, 
which may run an acute, subacute, or chronic course, all cases 
of nephritis may best be divided in the following manner : 

1. Catarrhal, interstitial, or desquamative nephritis. 

{a) Acute. 

(b) Subacute. 

(c) Chronic, terminating in cirrhosis of the kidney. 

2. Croupous or parenchymatous nephritis. 

(a) Acute. 

(b) Subacute. 

(c) Chronic, terminating in atrophy of the kidney. 

3. Suppurative nephritis or pyonephrosis. 

(a) Acute. 

(b) Chronic. 

It is hardly possible to speak of a subacute abscess, since all 
such cases which have lasted for a number of weeks are 
properly chronic. 



158 URINARY ANALYSIS AND DIAGNOSIS 

Congestion or hyperseinia of the kidney can not be considered 
as a separate affection, since it is either the first stage of a 
commencing inflammation, or a mere irritation, which can not be 
properly termed inflammatory as yet. but which sooner or later 
will undoubtedly develop into an inflammation. 

Glomernlitis or glomernlo- nephritis, again, is not an inde- 
pendent inflammatory process, but only a symptom of one of 
the inflammations, since the glomeruli will always be attacked 
to a greater or less degree in every nephritis. 

Fatty and waxy, or amyloid, degenerations of the kidney 
are always secondary products, due to a chronic inflammation, 
and part of such an inflammation. 

Pathological Changes. — Let us now briefly consider the 
pathological changes which take place in these different inflam- 
mations of the kidney : 

1. Catarrhal Inflammation. — In catarrhal or interstitial in- 
flammation of a mild character, an (Edematous swelling of the 
connective tissue is present, with swelling and granular cloudi- 
ness of the epithelial covering and subsequent desquamation of 
the epithelium. The blood-vessels show a more or less complete 
distension with blood -corpuscles, without apparent alteration in 
the structure of their walls. The cedematous swelling of the 
connective tissue, as well as the desquamation of the epithelia, 
are due to a serous exudation from the blood-vessels. On 
account of this serous exudation, the epithelia may become 
partly changed to mucus. 

In severer cases an inflammatory infiltration of the connec- 
tive tissue, which leads to hypertrophy, takes place, with pro- 
liferation, desquamation, and. finally, hyperplasia of the epi- 
thelium. In the highest degree of catarrhal inflammation. 
the constituent parts of the kidney -tissue have disappeared in 
the inflammatory infiltration. 

At the very commencement of an inflammation, the produc- 
tion of pus -corpuscles takes place, partly from the interstitial 
connective tissue and partly from the epithelium, which lattei 
undoubtedly enters into the formation of pus - corpuscles to 
great degree by division and endogenous cell -proliferation, as 
has been already shown by George Johnson, in the year 1852. 
As long as the newly formed corpuscles remain in connectioi 
with the tissue, we have inflammatory corpuscles ; but as soon 
as thev are torn from their connection with the tissue and 



DISEASES OF THE KIDNEY AND PELVIS 15D 

appear in the urine, the term pus -corpuscles must properly 
be applied to them. 

When the disease has become chronic, the surface of the 
kidney is marked by irregular, shallow depressions, or by 
granulations, the capsule being adherent in most cases. The 
irregular depressions are due to retractions of newly formed 
connective tissue, which is formed at the expense of the uri- 
niferous tubules. Chronic catarrhal or interstitial nephritis 
invariably leads to a shrinkage — cirrhosis — of the kidney. 
The whole kidney is considerably reduced in size and the 
irregularities on the surface are well marked. Both the cortical 
and medullary substances are much narrower than in the normal 
condition ; this being more particularly the case in the cortex, 
of which, in advanced stages, only slight remnants are left, 
corresponding with the elevations of the surface. There is a 
partial destruction of tufts or glomeruli, tubules, and blood- 
vessels. The newly formed connective tissue is more or less, 
regularly distributed throughout the kidney structure, the urinif- 
erous tubules being in part transformed into connective tissue, 
while still retaining the outlines of their original configuration. 

The obliteration of a number of the narrow tubules, including 
the ascending and descending branches, explains the clinical fact 
that persons affected with cirrhosis of the kidney void large quan- 
tities of urine almost destitute of salts. It is well known that 
the tuft excretes water only, which becomes thicker by the addi- 
tion of the saline constituents excreted by the narrow tubules. 
It is in the narrow tubules that much of the watery part of th& 
urine is restored to the thickened blood running in the neighbor- 
ing capillaries. If the function of the tubules be much interfered 
with, the interchange between the liquid contents of the tubule 
and the solid constituents of the blood will not take place, and 
consequently the urine will be voided in about the same condition 
in which it was pressed into the capsule from the tuft. Numbers 
of the convoluted tubules perish also through the increased for- 
mation of connective tissue, while from others the epithelia are 
simply desquamated and appear in the urine. 

2. Croupous Inflammation. — In croupous or parenchymatous 
inflammations, the surface becomes partially or completely de- 
nuded of its epithelium, a coagulated albuminous or fibrinous 
exudate is formed upon the surface, there is considerable hyperemia, 
of the blood-vessels, and a pronounced swelling and inflammatory- 



160 UBIX ART AXALTSIS AXD DIAGXOSIS 

infiltration of the connective tissue. E. Wagner has shown that 
the epithelia enter very actively in the formation of the so-called 
croup membrane, and their protoplasm becomes almost completely 
destroyed in the fibrinous exudate. 

In this variety of inflammation, the emigration of colorless 
blood -corpuscles is quite pronounced. Epithelia alone can not 
produce a croup membrane, but require the presence of an exudate 
from the blood, and the essential constituent of the croup 
membrane is the coagulable albuminoid body from the blood. 
We now have the formation of casts ; the epithelia lining the 
tubules become saturated with the albuminous exudate, swell, 
grow pale, and finally, by coalescence of the epithelia thus de- 
generated, produce the mass called a tubular cast. 

In chronic croupous nephritis, the kidney has an entirely dif- 
ferent appearance from that found in chronic catarrhal nephritis 
and cirrhosis of the kidney. It is more frequently enlarged than 
diminished in size. The surface is often nodulated, and between 
the nodules are seen deep cicatricial retractions. These retrac- 
tions are never found uniformly over the surface, and the capsule 
is adherent to the retractions. The cortical substance is 
absent in those parts corresponding with the retractions of the 
surface, while in other places the cortex may be unaltered or even 
increased in bulk. The pyramidal substance may be unchanged 
or may be diminished. In contradistinction to the more or less 
uniform shrinkage of the kidney, to which the name cirrhotic is 
given, the partial destruction of the tissue which occurs in 
chronic croupous nephritis may be termed atrophy, since in the 
most diseased portions only traces of the original kidney structure 
will be found. 

In the depressed cicatricial portions of the cortical substance, 
a large amount of connective tissue, only scantily supplied with 
blood-vessels, is found. There is no regularity in the arrange- 
ment of the connective tissue, and only remnants of the former 
tubules are found, together with irregularly scattered sections of 
tubules, from which the epithelial lining has entirely disappeared. 
In the most pronounced cases, in addition to the atrophied por- 
tions, the large amount of newly formed connective tissue present 
in different places constitutes a regular hypertrophy. 

Both fatty and waxy degeneration may be present in cirrhotic 
as well as in atrophied kidneys ; but these changes are much more 
pronounced in the latter than in the former. In the so-called 









DISEASES OE THE EIDXEY AND PELVIS 161 

large white kidney, the highest degree of fatty degeneration 
occurs as a secondary result of chronic croupous nephritis. Cystic 
degeneration may also be present in these cases, and is more 
pronounced in chronic croupous nephritis. 

3. Suppurative Inflammation. — The most intense variety of 
inflammation of the kidney is the suppurative, which is similar to 
the formation of an abscess in other organs. For a long time this 
variety was considered to be a purely interstitial inflammation, 
since the opinion prevailed that pus -corpuscles could only be 
formed from connective -tissue cells. There is, however, no doubt, 
as previously stated, that the epithelia take an active part in the 
formation of pus. The blood-vessels soon become destroyed in 
this variety. Pus is disintegrated tissue, and in its formation all 
the elements of the tissue take part. 

There may be either a number of small disseminated foci of 
suppuration or a large abscess, usually, if not invariably, caused 
by an invasion of pyogenic cocci. Besides the abscess, the kidney 
may present either the features of a catarrhal or of a croupous 
inflammation. When the abscesses become chronic, a dense 
connective -tissue capsule, the pyogenous membrane, may occasion- 
ally be found, and the pus becomes inspissated into a cheesy 
mass. 

With these remarks upon the pathology of the different varie- 
ties of nephritis, we are ready to understand the features found in 
the urine of these cases. Although it is not possible to diagnose 
an acute, subacute, or chronic inflammation from the urine alone, 
in all cases of nephritis, it can undoubtedly be done from the dif- 
ferent features seen in most cases, especially the more pro- 
nounced. 

IRRITATION OF THE KIDNEY 

From what has been said before, it is evident that the diag- 
nosis of an inflammation can be made as soon as pus -corpuscles 
are found in the urine ; without these, no such diagnosis is 
possible. In some cases, in which a trace of albumin is present, 
or no albumin whatever is found, an extremely small number of 
pus -corpuscles, perhaps one or two in every field of the micro- 
scope, is seen, together with the same number of epithelia from 
the convoluted tubules of the kidney, and a few red blood -cor- 
puscles. These features, when present in such very small num- 
bers, are not sufficient for the diagnosis of an inflammation, 



162 UBINAMY ANALYSIS AXD DIAGNOSIS 

though the urine can not be called normal. In such cases the 
diagnosis of an irritation of the kidney is possible, and in them 
we will never find casts. As soon as casts are present, even if 
the features are very scanty, an inflammation must be diagnosed. 

In some, though uot in all cases of irritation, an increase of 
mucus, both in the form of threads and corpuscles, is noticeable. 
When this is present, caution is necessary, since such an increase 
of mucus is often seen as a pre -stage of an inflammation, es- 
pecially in acute eruptive and inflammatory diseases, such as 
scarlet fever, diphtheria, and pneumonia. 

Causes. — Irritation of the kidney is of common occurrence, 
but is frequently overlooked. It may be present accompanying 
almost any disease, aud may be produced by different mediciual 
agents, such as cubebs. copaiba, turpentine, cantharides. and 
mineral acids. Occasionally it seems as if simple exposure to 
cold aud moisture is sufficient to produce it. In cases of 
catarrhal or gonorrhoeal urethritis, especially if accompanied 
by slight prostatitis, irritation of the kidney is often found. 
The presence of an increased amount of salts, such as uric acid 
or oxalate of lime, will not infrequently be responsible for 
the condition. 

If the cause which has produced the irritation be quickly 
removed, the affection may disappear at once : but if not. an 
inflammation will sooner or later result. 

If the irritation is pronounced, a more or less severe hem- 
orrhage from the kidney may take place, even without an 
inflammation. In such cases, red blood -corpuscles will be 
numerous, epithelia from the convoluted tubules may be some- 
what more abundant, aud, in addition, scanty, delicate shreds of 
connective tissue will appear in the urine. All the features may 
have a yellowish hue from the coloring matter of the blood. 

CATARRHAL OR INTERSTITIAL NEPHRITIS 

Catarrhal, interstitial, or desquamative nephritis frequently 
runs a comparatively mild course, being, as a rule, the mildest 
of the three varieties of inflammations. Severe acute cases. 
which may cause the death of the patient, do however, occur. 
Catarrhal nephritis is a much more common affection than is 
generally supposed, and may exist for many years without 
giving any pronounced clinical symptoms. It is by no means 



DISEASES OF THE KIDNEY AND PELVIS 163 

rare that a urine which is examined microscopically with a 
view of detecting other affections will show the presence of 
such an inflammation before the clinical symptoms are clear, 
though the patient m&y have suffered for a long time from 
occasional headaches and general depression. 

Causes. — Catarrhal nephritis often exists in a mild degree 
without any known cause. Exposure to cold and moisture 
seems to be a frequent cause, as are also different medicinal 
agents, such as arsenic, iodine, phosphorus, mercury, turpen- 
tine, and cantharides. In lead -poisoning the disease is often 
present. It is not infrequently found in persons of sedative 
habits and in those with a so-called gouty or rheumatic diath- 
esis. That persons suffering from gout and rheumatism usu- 
ally void a large amount of uric acid is well known ; but there 
are others who continually void uric acid and oxalate of lime 
in excess without giving any rheumatic symptoms. In these 
cases — litha?mia and oxaluria — catarrhal nephritis frequently 
occurs, and it seems that the excess of the salts, or the concen- 
tration of the urine itself, has an irritating tendency upon the 
kidney tissue. The continued use of alcohol is an important 
factor in the production of the disease. 

In acute contagious diseases, croupous nephritis is of more 
common occurrence than catarrhal, but the latter, contrary to 
the general belief, undoubtedly occurs. If the urine is care- 
fully examined in these diseases, a small amount of albumin, 
perhaps not more than a trace, may be found in the milder 
cases, and upon microscopical examination the features of a 
catarrhal inflammation are seen. Even in some fatal cases, an 
examination of the kidney may reveal a catarrhal and not a 
croupous inflammation. In pregnancy, also, catarrhal nephritis 
may occur, though rarely. 

As a secondary affection, this variety of inflammation may 
be present in many acute and chronic fatal diseases, so much 
so that, upon post-mortem examinations, absolutely healthy kid- 
neys are usually found only after death by accident. 

Finally, catarrhal nephritis is common as a result of vari- 
ous genito- urinary affections, as, for instance, in some cases 
of gonorrhoea, when first a prostatitis, then, in succession, a 
cystitis, pyelitis, and nephritis will develop. In syphilitic and 
tubercular affections it is frequently seen. 

Clinical Symptoms. — The clinical symptoms of the disease 



161 URINARY ANALYSIS AND DIAGNOSIS 

vary greatly, but in the milder eases are anaemia, occipital 
headache, pain in the lumbar region, loss of appetite, sleep- 
lessness, and general depression. In cirrhosis of the kidney 
the symptoms are pronounced, loss of flesh and strength is well 
marked, vomiting may be frequent, there may be dyspnoea, and 
the pulse is tense, hard, and often full. The acute cases may 
occur at any age, but the chronic cases are mostly found in 
persons more advanced in years, especially after the age of 
forty years . 

Features Found in Urine. — Albumin, although present in 
most of the cases, may be found iu very small amount only, 
and in some it seems to be entirely absent. A large amount of 
albumin is rare in catarrhal nephritis, and is seen only in the 
severe cases. In many, a trace of albumin only -will be found, 
and unless a careful observation is made, it may escape detec- 
tion entirely. The question whether a pronounced inflammation 
of the kidney may exist with entire absence of albumin is still 
an open one. Many authors claim that it does occur, but many 
times when albumin is said to be absent, careful examination 
will show a trace. It is undoubtedly a fact that in catarrhal 
nephritis albumin may be absent at certain times ; but frequent 
examination will almost invariably show at least a trace in 
every case. 

The specific gravity, amount, and appearance of the urine 
will vary greatly. In milder cases, these may be perfectly nor- 
mal. In acute catarrhal nephritis the specific gravity is, as a 
rule, somewhat higher than normal, the amount slightly de- 
creased, and the color darker. The amount of urea is usually 
increased, and salts may be present in rather large numbers. 
In chronic cases the amount of urine is invariably increased, 
sometimes to a great degree ; the specific gravity is low, and 
the color pale. In such cases the specific gravity is not infre- 
quently below 1.015 or 1.012 continually, the amount of urea 
and salts being diminished. The sediment found in the urine 
varies, but is usually small, and may, at times, be no more 
abundant than in normal urine. 

A positive diagnosis of catarrhal or interstitial nephritis is 
in many cases possible only by a microscopical examination of 
the urinary sediment. This will vary in acute, subacute, and 
chronic cases. The diagnosis of a nephritis can be made when 
pus -corpuscles and epithelia from the convoluted and narrow 






DISEASES OF THE KIDNEY AND PELVIS 105 

tubules of the kidney are present in the urine. Columnar epi- 
thelia from the straight collecting tubules are of rarer occur- 
rence, and indicate an invasion of the pyramidal substance. 

Before the presence of epithelia from the convoluted tubules 
of the kidney can be diagnosed, pus -corpuscles must be found 
and taken as a standard, since the latter vary in size to a cer- 
tain degree in every given case. Kidney epithelia from the 
convoluted tubules are invariably one -third larger than the pus- 
corpuscles. These epithelia are never found in normal urine, 
and to render their diagnosis positive, should always be com- 
pared with pus- or white blood -corpuscles. A single kidney 
epithelium is of no value for the diagnosis, as a small number, 
at least, should always be found, in order to render the 
diagnosis positive, since, as is well known, pus -corpuscles will 
vary in size to a small degree even in the same case. This 
difference is, however, small, and never so pronounced as to 
render the diagnosis between pus -corpuscles and kidney epithelia 
difficult. The difference in size between the two can alone 
determine the nature of the epithelia, since the presence or 
absence of a nucleus has no significance whatever. A nucleus 
may be seen in pus -corpuscles as well as in epithelia, though 
it is found more frequently in the latter than in the former. 
In finely granular pus -corpuscles a nucleus will always be 
visible, while in coarsely granular epithelia it may not be seen. 

Kidney epithelia from the convoluted, as well as those from 
the narrow tubules will, in urine generally, have a round 
form ; angular or irregular forms are rarely seen. When 
the urine is still warm at the time of examination, or in a 
warm temperature, the pus -corpuscles may not infrequently 
show amoeboid movement, and assume a variety of different 
shapes while the kidney epithelia will, as a rule, retain their 
round form. 

In this variety of nephritis easts are usually absent ; if they 
are present at all, they are found in extremely small numbers, 
and then we almost invariably see small hyaline casts from the 
narrow tubules only. The diagnosis, however, hinges upon the 
presence of epithelia from the convoluted and narrow tubules 
and pus -corpuscles, together with other features to be presently 
mentioned. 

Acute Catarrhal or Interstitial Nephritis (Fig. 81). — In an 
acute catarrhal nephritis the pus -corpuscles and cuboidal epi- 



166 URINARY ANALYSIS AND DIAGNOSIS 

thelia from the convoluted tubules of the kidney are present 
in at least moderate but usually large numbers ; the more 
numerous these features, the severer is the nephritis. Besides 
these, we usually find red blood -corpuscles in moderate or large 
numbers, though they are not sufficiently numerous to admit 
of the diagnosis of a haemorrhage . Larger numbers of red 
blood -corpuscles always indicate an acute inflammation. 

These three features are perfectly sufficient for the diagnosis, 
but are rarely found alone. In many cases different salts, such 
as oxalate of lime, uric acid, and urate of sodium, will be found 
in small amount. In the severer cases a few columnar epi- 
thelia from the straight collecting tubules are also present. 
As a general rule, an inflammation of the pelvis of the kidney 
is associated with the nephritis, though this may be absent. 
When present, the irregular, lenticular, pear - shaped, or angu- 
lar epithelia from the pelvis will also be seen in varying 
numbers, and the diagnosis of a Pyelo -nephritis can be made. 
Such a diagnosis does not by any means suggest an abscess 
of the kidney, as is frequently supposed, but simply the ex- 
tension of the inflammatory process to the pelvis of the kidney. 
Besides these, epithelia from the ureters in small numbers, 
which are twice the size of pus -corpuscles, and therefore larger 
than the kidney epithelia, are rarely absent. 

If the nephritis is at all pronounced, symptoms of an accom- 
panying cystitis are also seen, and we will then find larger 
cuboidal epithelia from the middle layers of the bladder — which 
in urine appear round or oval in most cases — as well as flat epi- 
thelia from the upper layers with the other features. 

The severer the acute inflammation the more certain are the 
accompanying features of pyelitis and cystitis. In such severe 
cases hyaline casts from the narrow tubules are occasionally 
present ; if these are seen in small numbers only, the diagnosis 
does not necessarily become changed. The latter feature is com- 
paratively rare, and in most cases casts of any kind are 
entirely absent. 

Chronic Catarrhal or Interstitial Nephritis (Fig. 82). — As 
soon as the inflammation has become chronic, the features in the 
urine are different. Red blood -corpuscles are now either entirely 
absent, or, when present, are found in small numbers only. We 
observe, however, a varying number of small, glistening, highly 
refractive globules and granules, partly lying free, partly in the 










Fi«. 81. Acute Catarrhal Pyelonephritis (Acute Interstitial Nephritis) 
and Cystitis (X 500). 

RB, red blood-corpuscles ; PC, pus-corpuscles ; CE, epithelia from the convoluted tubules 
of the kidney ; UE, epithelia from the ureter ; PE, epithelium from the pelvis of the kidney ; 
UB, epithelium from the upper layers of the bladder ; MB, epithelium from the middle layers of 
the bladder. 



(167) 



9 ® 




Fig. 82. Chronic Catarrhal Pyelonephritis (Chronic Interstitial 
Nephritis) and Cystitis (X 500). 

PC. pus-corpuscles containing fat-globules; CE, epithelia from the convoluted tubules of 
the kidney containing fat-globules j SE, epithelium from the straight collecting tubules of the 
kidney containing fat-globules ; UE, epithelia from the ureter containing fat-globules ; PE, 
epithelia from the pelvis of the kidney ; MB, epithelia from the middle layers of the bladder ; 
FG, free fat-globules. 



(168) 



DISEASES OF THE KIDNEY A XT) PELVIS 169 

pus -corpuscles and epithelia. These are fat - globules and 
-granules, and the more numerous they are, the more chronic is 
the inflammation. They are found in larger or smaller groups 
scattered throughout the field, and are seen in varying numbers 
in the pus -corpuscles and epithelia. In milder cases only two or 
three may be present in some epithelia, while they will be absent 
in others ; but in the old, chronic cases, almost every epithelium 
will be seen filled with the glistening globules. When very 
numerous, they not only denote chronicity, but also a commencing 
fatty degeneration of the kidney, which, in this variety of 
nephritis, is never pronounced. Fat -globules are not seen in 
acute cases. 

The features found in a chronic catarrhal nephritis are, there- 
fore, the following : Pus-corpuscles, some containing fat- globules 
and -granules ; cuboidal epithelia from the convoluted tubules of 
the kidne}*, a few, or the larger number, containing fat -globules ; 
free fat- globules in different groups ; in the severer cases, also, 
columnar epithelia from the straight collecting tubules, usually in 
small numbers only. Irregular or round epithelia from the pelvis 
of the kidney, cuboidal (round) epithelia from the ureters, and 
still larger cuboidal epithelia from the middle layers of the blad- 
der, either with or without fat -globules, may be present in small 
or moderate numbers. 

Another feature of chronicity which may occasionally be 
found is haematoidin, in the form of rust -brown needles and 
plates. These may either lie free, or when of small size may be 
seen in the pus -corpuscles and epithelia. They denote a pre- 
viously existing haemorrhage, and show that the pathological 
process can not be an acute one. 

Red blood -corpuscles, as previously mentioned, are either 
entirely absent in a strictly chronic case, or, when present, are 
found in small numbers only. Not infrequently, however, all the 
features of a chronic inflammation are seen, and yet blood- 
corpuscles are numerous. This invariably denotes a fresh acute 
outbreak engrafted upon the chronic process. Such acute attacks 
are not rare in cases of long standing, and may be produced by 
the slightest cause, such as exposure to cold, derangements of 
digestion, etc. Again, the chronic inflammation may be confined 
to one kidney and an acute process affect the second kidney. 

In Subacute Catarrhal Inflammations some features of both 
the acute and the chronic form will be found. We have a small 



170 UBIXAEY ANALYSIS ASD DIAGNOSIS 

or moderate number of red blood -corpuscles and a small number 
of fat- globules, the latter being rarely seen in groups, but only in 
a few pus-corpuscles and epithelia, and there may be only one, two, 
or three in them. The other features remain the same. 

When the features as here described are present, it will not be 
difficult to tell whether an inflammation is acute, subacute, or 
chronic ; but some cases may at times be seen where neither red 
blood-corpuscles nor fat -globules can be discovered, and then the 
diagnosis of a simple catarrhal or interstitial nephritis can 
alone be made. These cases are usually of a mild character. 

Besides all these features, the appearance of the pus- corpuscles, 
as noted in a previous chapter, must be taken into consideration, 
and may help to clear up the case where the clinical features and 
the history are vague. As long as the constitution of the patient 
is still fairly good, which can easily be determined by the number 
of coarsely and finely granular pus -corpuscles present in the 
case, we may feel confident that the nephritis can not have lasted 
any length of time, nor be a severe one. 

Cirrhosis of the Kidney (Fig. 83). — The outcome of chronic 
catarrhal nephritis is always a shrinkage — cirrhosis — of the 
kidney, the so-called hob -nail kidney. The features of this, as 
seen in the urine, are so characteristic that a positive diagnosis 
can always be made. They are the following : 

1. A large amount of urine, being occasionally increased to 
double the normal quantity, and the color being pale. 

2. A continuously low specific gravity, usually below 1.012 
or 1.010, or even not more than 1.006 at any time. 

3. The presence of a small amount or perhaps but a trace 
of albumin . 

4. The absence of all salts. 

5. Pus -corpuscles, present in small numbers, some contain- 
ing fat -globules. 

6. Epithelia from the convoluted and straight collecting 
tubules of the kidney, in small numbers, some or even all con- 
taining fat -globules. 

7. Free fat -globules and -granules. 

8. Connective -tissue shreds, of small sizes and in small 
numbers only. 

9. Broken down constitution, as seen by the pale, finely 
granular pus -corpuscles, iu which not infrequently one or more 
nuclei become plainly visible. 




Fig. 83. Cirrhosis of the Kidney, with Chronic Catarrhal 
Cystitis (X 500). 

PC, pus-corpuscles ; CE, epithelia from the convoluted tubules of the kidney, containing 
fat-globules ; SE, epithelium from the straight collecting tubules of the kidney ; UE, epi- 
thelium from the ureters ; PE, epithelium from the pelvis of the kidney ; MB, epithelium 
from the middle layers of the bladder ; CT, connective-tissue shreds ; FG, free fat-globules. 



(171) 



172 URINABY ANALYSIS AND DIAGNOSIS 

Epithelia from the pelvis of the kidney, the ureter, and the 
middle layers of the bladder may also be present. 

As previously explained, a badly diseased kidney can never 
void any salts. In some cases, in which all the other features 
of a cirrhosis are present, a large amount of salts, such as uric 
acid or phosphates are also seen. The conclusion which can 
then be reached, is that only one kidney has so far become 
affected, the salts being voided by the other kidney. The 
prognosis will, in such cases, be better than when all salts 
are absent. 

Catarrhal Pyelitis. — A few words should here be said about 
catarrhal pyelitis, which is occasionally a primary, independent 
affection. When it occurs as such, it is easily diagnosed from 
the urine, the features being the same as in catarrhal nephritis, 
except that pelvic epithelia instead of kidney epithelia are found. 
Being in many cases due to an abundance of salts, these will 
usually be present in such cases. As a rule, pyelitis is an 
accompanying element of a nephritis, giving us a catarrhal 
pyelo -nephritis, with the features as above described. 

CROUPOUS OR PARENCHYMATOUS NEPHRITIS 

Croupous nephritis is usually a severer affection than the 
catarrhal, and is not quite as frequent as the latter. When pres- 
ent, its symptoms are always more or less pronounced, and 
only in rare cases will it exist for some time without giving 
symptoms sufficiently characteristic to suspect a nephritis. 

Causes.— Its causes are numerous, being partly the same as 
those found in the catarrhal variety. Exposure to cold and 
moisture is a common cause, and it is not infrequently the con- 
sequence of irritant poisons acting upon the system, such as 
turpentine, bichloride of mercury, cantharides, arsenic, large 
doses of iodide of potash, and, occasionally, even chlorate of 
potash. As in catarrhal nephritis, it may be found in persons 
of a sedative habit and in those suffering from a lithaemia. 
The continued use of alcohol is an important causative factor. 

Among the most common causes in the production of the 
disease are the acute eruptive and inflammatory diseases, espe- 
cially scarlatina, diphtheria, and pneumonia ; less frequently 
typhoid fever and small -pox. It is occasionally seen during 
pregnancy, though it is not always easy to account for its 



DISEASES OF THE KIDNEY AND PELVIS 173 

occurrence ; pressure produced by the gravid uterus may be 
partly responsible for it. In chronic affections, such as heart 
diseases, tuberculosis, and syphilis it may also be seen, as 
well as in rarer cases of malarial poisoning. 

As a result of strictures of the urethra, prostatitis, and 
hypertrophy of the prostate gland, croupous nephritis is fre- 
quent. The original inflammation will cause a cystitis, and, 
from the bladder, ascend to the ureters, pelves, and kidneys, 
ending in a croupous nephritis. A peculiar occurrence is its 
appearance in strong, healthy athletes during active training, 
especially when they subsist upon a meat diet ; the same may 
be the case in fat people who desire to reduce their weight 
quickly by an exclusive meat diet. 

Clinical Symptoms. — The clinical symptoms vary with the 
intensity of the process, though anaemia, headache, loss of 
appetite, emaciation, nausea, and loss of strength are all gen- 
erally present. Severe acute cases ma} r be ushered in by 
chills, followed by a rise in temperature. Very soon oedema 
will appear, first being localized, especially on the eyelids, but 
soon becoming general, involving the face, hands, feet, and 
cellular tissues generally. To these symptoms will be added 
dull, aching pains in the lumbar region, and, in the severe 
cases, ursemic symptoms. 

Features Found in Urine. — Albumin is almost invariably 
present in comparatively large amount, and in some cases may 
be extremely abundant, reaching one -half of 1 per cent, or 
even more. It is claimed that occasionally croupous nephritis 
may exist without the presence of any albumin ; that it may 
exceptionally occur in small quantities only is undoubted ; 
but it will probably never be absent altogether, as careful 
tests for albumin will show. 

In acute croupous nephritis the amount of urine is usually 
decreased, sometimes to a great degree, and in the severer and 
fatal cases may sink to a few ounces in the twenty -four hours, 
or may even be practically suppressed. The specific gravity is 
in many cases higher than normal, often reaching 1.030 or 
more, and the color dark, being sometimes quite pronounced, 
since haemorrhages frequently occur. The amount of solids, 
especially urea, voided during the twenty-four hours is usually 
decreased to a greater or less degree. In chronic nephritis the 
amount of urine is also at first decreased, but later becomes 



174 



URINARY ANALYSIS AND DIAGNOSIS 



more abundant, though never in as pronounced a degree as in 
chronic catarrhal inflammation. The specific gravity will grad- 
ually become lower, until in atrophy of the kidney it is never 
more than 1.012, or even less. The color varies, being pale in 
the later stages. The sediment found in the urine is always 
quite abundant, and when once separated does not readily mix 
with the watery portion. 

As in catarrhal nephritis, a positive diagnosis of croupous 
or parenchymatous nephritis is. in many cases, possible only 
from a microscopical examination of the urinary sediment, 
This will vary considerably in acute, subacute, and chronic 
cases. In this variety of nephritis the presence of casts in 
larger or smaller numbers is a constant feature, without which 
the diagnosis can never be made, and the greater the number 
of casts, the worse, as a rule, the inflammation. True casts 
will, however, never be found in urine without the presence 
at the same time of pus -corpuscles and kidney epithelia, the 
latter not only from the convoluted and narrow tubules, but 
frequently, also, from the straight collecting tubules, though 
these may be absent in mild cases. 

The varieties and sizes of the casts are of great importance 
for the diagnosis and prognosis. In strictly acute cases we 
never expect to find either granular, fatty, or waxy casts, 
while hyaline and epithelial casts are always present in larger 
or smaller numbers, and blood casts in the severer, hemor- 
rhagic forms. Again, the severity of the process can easily be 
determined by the size of the casts — when the smallest casts 
from the narrow tubules alone are present in small numbers, 
the parenchymatous nephritis will be of a mild character, and 
recovery is the rule. Casts from the convoluted and narrow 
tubules together, the former being of medium size, denote a 
process of moderate severity ; but as soon as the largest casts, 
coming from the straight collecting tubules, are present with 
the other varieties, we know that the inflammatory process has 
affected the whole kidney, that is, both cortical and pyramidal 
substance, and is a severe one ; Iherefore a doubtful prognosis 
only can be given. 

Acute Croupous or Parenchymatous Nephritis (Fig. 84). 
— When we examine the urine from a case of acute croupous 
nephritis, the features are found to be numerous and character- 
istic. The most pronounced elements are undoubtedly the casts, 




Fig. 84. Acute Croupous or Parenchymatous Nephritis with Catarrhal 
Pyelitis and Cystitis (X 500). 

RB, red blood-corpuscle ; PC, ptis-corpuscles ; CE, epithelia from the convoluted tubules 
of the kidney ; UE, epithelia from the ureter ; PE, epithelia from the pelvis of the kidney ; 
UB, epithelia from the upper layers of the bladder ; MB, epithelia from the middle layers of 
the bladder ; K, creatinine crystal ; HC, hyaline casts ; EC, epithelial cast ; MS, mucus- 
thread ; MC, mucus-casts : CT, connective-tissue shred. 



(175; 



176 URINARY ANALYSIS AND DIAGNOSIS 

which are seen in varying numbers in every field of the micro- 
scope. In such cases, two varieties of casts are usually found — 
the hyaline and the epithelial, the latter studded with epithelia 
to a greater or less degree. The more numerous the casts, the 
severer the inflammation, and the more albumin the urine will 
usually contain. 

Besides the casts, pus -corpuscles, red blood -corpuscles, and 
epithelia from the convoluted tubules are always present. They 
are found in moderate or large numbers, the kidney epithelia 
being frequently seen massed together. Red blood -corpuscles 
are found in every field, though, unless a haemorrhage has taken 
place, they cannot be called very abundant. Epithelia from the 
straight collecting tubules may also be seen, and those from the 
ureter and pelvis of the kidney almost invariably accompany 
the other features. As a rule, there will also be an accompany- 
ing acute cystitis, shown by the presence of epithelia from the 
upper and middle layers of the bladder. 

In these acute cases, mucus is present in fairly large amount, 
the pale threads being sometimes of considerable size, irregular, 
and finely striated. Not infrequently mucus is found in the 
form of casts — the so-called cylindroids. The presence of these 
has no further significance than the presence of mucus in gen- 
eral, and they may be seen in inflammations of any one of the 
genito- urinary organs. When they exist in a pronounced form, 
they can hardly be mistaken, as they are always faintly striated; 
but not infrequently they are so faint that their striation 
becomes visible only upon sharp focusing, and caution is here 
necessary not to mistake them for hyaline casts, which is fre- 
quently done. In size and shape they may resemble hyaline 
casts, which latter, however, are never striated. When they 
assume an irregular, convoluted form, their diagnosis is easy. 

In the severer cases of acute croupous nephritis, small shreds 
of connective tissue will be present ; they are never large or 
numerous, and their higher refraction and pronounced fibrillary 
structure is sufficient to differentiate them from mucus. Besides 
these features, crystals of creatinine may be present in those 
cases in which uraemic convulsions have made their appearance. 
The plate is taken from a case of severe nephritis, which devel- 
oped in the third week of scarlet fever, and caused the death of 
the patient. The urine contained large numbers of character- 
istic creatinine lozenges and plates. 




Fig. 85. Acute Hemorrhagic Croupous cr Parenchymatous Nephritis with 
Catarrhal Pyelitis and Cystitis (X 500). 

RB, red blood-corpuscles ; PC, pus-corpuscles ; CE, epithelia from the convoluted tubules 
of the kidney ; SE, epithelia from the straight collecting tubules of the kidney ; UE, epithelium 
from the ureter ; PE, epithelium from the pelvis of the kidney ; MB, epithelium from the mid- 
dle layers of the bladder ; HC, hyaline casts ; EC, epithelial cast ; BC, blood casts ; CT, con- 
nective-tissue shred. 



(177) 



178 UEIXAEY AXALYSIS JJXD DIAGXOSIS 

Besides the eases just described, severe cases with pronounced 
haemorrhages are often seen, and will give somewhat different 
features (Fig. 85). 

The urinary sediment contains a large number of red blood- 
corpuscles in every field, together with many blood casts. The 
blood casts are partly filled with red blood -corpuscles, which 
have retained their normal appearance, and partly with disinte- 
grated blood -globules, in the form of irregular brown masses, 
giving to the whole cast a rust -brown appearance ; blood casts 
assume this character when they have been retained in the tub- 
ules for some time. Sometimes the larger portion of the cast 
contains fully formed red blood -corpuscles, while the disintegra- 
tion has commenced in a small portion. Besides these casts, 
hyaline and epithelial casts are found in large numbers, and in 
these cases we almost invariably find large casts from the 
straight collecting tubules. 

Epithelia from the straight collecting tubules are usually 
quite abundant, aud connective -tissue shreds are larger and more 
numerous than in the preceding. In an active haemorrhage such 
connective -tissue shreds are cast off in fair numbers and found 
in the urine. Sometimes masses of fibrin are also found. The 
other features are the same, there being in most cases an accom- 
panying iuflammation of the pelves, the ureters, and the bladder. 

Subacute Croupous Nephritis (Fig. 86). — After a croupous 
or parenchymatous nephritis has lasted for some time, the casts, 
or rather some of the casts, commence to change. Such a change 
is rarely noticed until four or six weeks after the coinniencement 
of the inflammation, but occasionally, especially in nephritis after 
scarlet fever in children, may take place in two or three weeks. 

The first change will be seen in the epithelial casts, some of 
the epithelia breaking down into granules, giving us an epithelial- 
granular cast. Very soon, however, perfect granular casts, with- 
out any trace of epithelia. are also found in small or moderate 
numbers, aud these, in exceptional cases in children, can be seen 
as early as two weeks after the inflammation has started, being 
then scanty. 

The next change which takes place is the transition of the 
granules into glistening, refractive fat-granules and -globules, at 
first only two or three being noticeable in a granular cast, and 
later on a larger number. Traces of the original epithelia may 
still be seen in the cast, while the largest portion has become 




Fig. 86. Subacute Croupous or Parenchymatous Nephritis with Catarrhal 
Pyelitis and Cystitis (X 500). 

RB, red blood -corpuscle ; PC, pus-corpuscles ; CE, epithelia from the convoluted tubules 
of the kidney; SE, epithelium from the straight collecting tubules of the kidney; UE, epi- 
thelia from the ureters ; PE, epithelium from the pelvis of the kidney ; UB, epithelia from 
the upper layers of the bladder ; MB, epithelia from the middle layers of the bladder ; 
HC, hyaline cast ; EC, epithelial cast ; GC, granular cast ; GF, granular-fatty cast ; EGF, epi- 
thelial-granular-fatty cast ; MS, mucus-thread ; MC, mucus-cast ; CT, connective-tissue shred ,• 
FG, free fat-globules. 

(179) 



Ir. rEIXABY ANALYSIS AND DIAGNOSIS 

changed into grannies, and some of the grannies into fat-globules, 
and we now have epithelial - granular-fatty eas:s. When the in- 
flammation has lasted for six weeks or two months, small groups 
of free fat -globules, at first scanty, are also found, and a few 
globules are seen in the epithelia. 

The other features, usually present in moderate numbers only, 
are the same as in an acute croupous nephritis, and eonnective- 
tissue shreds are scanty, unless the case is a severe one. Mucus- 
threads and casts may at times be pronounced, and the accompa- 
nying inflammations, especially in the bladder, are well marked. 

Chronic Croupous Nephritis. — The longer a nephritis lasts, 
the more marked are the changes in the casts, and in strictly 
chronic cases neither hyaline nor epithelial casts are seen in the 
urine. The granular casts are the most abundant in the milder 
forms, though a few fa: ists or granular-fatty casts are also 
present. The groups of free fat-globules, as well as the fat- 
globules in the epithelia and pus-corpuscles, become more numer- 
ous and more pronounced. 

In almost all cases of chronic croupous or parenchymatous 
nephritis, which have lasted for many months, and, instead of 
abating have become more pronounced, a fatty degeneration of 
the kidney will develop, and we now have the so-called large 
white kidney (Fig. 81 

In these cases, the fatty casts are abundant, and the large 
casts from the straight collecting tubules are frequently seen in 
conjunction with the smaller casts. The fatty changes in the 
pus-corpuscles and epithelia are well marked, and the groups 
of free fat-globules and -granules large and numerous. Et> 
too, individual fat -globules, much larger than those ordinarily 
seen, and sometimes attaining three or four times their size, or 
even more, may be present. In rare cases, needles of margaric 
acid in small numbers are found, but these are exceptional. 
Red blood -corpuscles are scanty in the majority of these cases. 

Connective -tissue shreds are always present, and may attain 
larg^ sixes >eing fairly abundant. The evidences of chronicity. 
_own by the fat -globules, will be seen in all epithelia found 
in the urine : that is. both those from the convoluted and 
straight collecting tubules of the kidney, from the pelvis, the 
ureters, and the bladder. The epithelia from the straight col- 
lecting tubules are sometimes numerous, and may be jus: 
abundant as the euboidal epithelia. Pelvic epithelia are t 




Fig. 87. Chronic Croupous or Parenchymatous Nephritis with Fatty 

Degeneration of the Kidney, Accompanying Catarrhal Pyelitis 

and Cystitis (X 500) 

PC, pus-corpuscles ; CE, epithelia from the convoluted tubules of the kidney; SE, epithelia 
from the straight collecting tubules of the kidney ; UE, epithelium from the ureter ; PE, epi- 
thelia from the pelvis of the kidney ; MB, epithelia from the middle layers of the bladder ; 
GC, granular cast ; PC, fatty casts ; GF, granular-fatty casts ; CT, connective-tissue shreds ; 
FG, free fat-globules. 



(181) 




Fig. 88. Chronic Croupous or Parenchymatous Nephritis, with Fatty and 
Waxy Degeneration of the Kidney, Accompanying Catarrhal Pyelitis 
(X 500). 

PC, pus-corpuscles ; CE, epithelia from the convoluted tubules of the kidney ; SE, epithelia 
from the straight collecting tubules of the kidney ; UE, epithelia from the ureter ; PE, epithe- 
lia from the pelvis of the kidney; GO, granular cast; GF, granular-fatty cast ; FC, fatty cast; 
WC, waxy cast ; WP, waxy-fatty cast; MS, mucus-thread ; CT, connective-tissue shred; FG, 
free fat-globules. 

(182) 



DISEASES OF THE KIDNEY AND PELVIS 183 

absent, and those from the ureters are well marked. That a 
cystitis of varying degrees of intensity is always present need 
hardly be mentioned. 

Besides the fatty degeneration, a waxy or amyloid degenera- 
tion of the kidney is found in a number of eases. Some authors 
call this an amyloid disease of the kidney and claim that it is 
an independent affection, and not associated with a parenchy- 
matous nephritis. This view is undoubtedly incorrect, as a 
waxy degeneration of the kidney is always a secondary affection 
found in chronic cases of nephritis. The exact cause and 
nature of such a degeneration are not known, and it is mostly 
found in chronic diseases, such as syphilis, tuberculosis, suppura- 
tive processes, ulcerations, and necroses. It seems to be due to 
some chemical change in the plasma of the blood, though the 
nature of this change is unknown. 

Waxy degeneration of the kidney may occur in both catarrhal 
and croupous nephritis ; it is much more common in the latter, 
and is rare in the former. It invades the epithelia of the urinif- 
erous tubules, and ultimately produces waxy casts. Epithelia 
which have become waxy are highly glistening, and are found in 
the urine as more or less shining, homogeneous bodies. Not 
only the epithelia, but also the connective tissue, and simultane- 
ously the walls of the blood-vessels, may undergo waxy degen- 
eration. 

The appearance of the urine is not characteristic of this 
degeneration, and it will present the features of a chronic ne- 
phritis, though the amount of sediment greatly varies, being 
sometimes slight, sometimes abundant. The specific gravity is 
usually low, and the amount of urine voided above normal. 
The diagnosis should never be made unless the changes in the 
urinary features are pronounced, and care must be taken not to 
mistake hyaline casts, which may in rare cases be somewhat 
glistening, for waxy casts. 

In chronic croupous nephritis with waxy degeneration of the 
kidney, the most characteristic features are the waxy casts 
(Fig. 88). 

Waxy casts may occur in all sizes, are always of a high re- 
fraction, have wavy, convoluted contours, and frequently a yel- 
lowish color. The casts may assume different forms, and not 
rarely are so tortuous as to be likened to a cork-screw. In most 
cases, all the three sizes of waxy casts will be found, and they 



184 URINARY ANALYSIS AND DIAGNOSIS 

may sometimes be mixed with other elements, such as granules — 
the granular -waxy ; or with fat -globules — the fatty -waxy casts. 
The other features are the same as those in any chronic croupous 
nephritis. Pus -corpuscles are always present, as well as differ- 
ent epithelia, connective -tissue shreds in large numbers, and 
granular as well as fatty casts. The appearance of a waxy 
degeneration is always of grave import, though even here re- 
coveries have occurred, especially in children. 

Cystic degeneration, which is also a secondary change, found 
in chronic cases of nephritis, does not give any characteristic 
symptoms in the urine, and, therefore, can not be diagnosed as 
such. 

Atrophy of the Kidney. — The result of a chronic croupous or 
parenchymatous nephritis is invariably a tropin of the kidney. 
The features of atrophy, as found in the urine, are characteristic, 
and a positive diagnosis can always be made, though the amount 
of urine voided in the twenty -four hours varies, and is never as 
abundant as in cirrhosis of the kidney. The features are the 
following : 

1. A continuously low specific gravity, as a rule, never above 
1.010, and occasionally not more than 1.006 or 1.004 at any time. 

2. The presence of a large amount of albumin, in contradis- 
tinction to the small amount found in cirrhosis. 

3. The absence of all salts. 

4. Pus-corpuscles, present in moderate numbers, many, if not 
all containing fat -granules and -globules. 

5. Epithelia from the convoluted and straight collecting 
tubules of the kidney, in moderate numbers, many or all contain- 
ing fat- granules and -globules. 

6. Free fat -granules and -globules, sometimes in large 
numbers. 

7. Granular, fatty, and, in some cases, even waxy casts in 
varying numbers, the former being usually quite abundant. 

8. Connective -tissue shreds of moderate or large size, and 
always in at least fair numbers. 

9. Broken down or poor constitution, as seen by the pale, 
finely granular pus -corpuscles, in which one or more nuclei are 
usually visible. 

Epithelia from the pelvis of the kidneys, the ureters and the 
middle layers of the bladder will be present in variable numbers. 
Here, again, attention must be called to the fact that a badly 






DISEASES OF THE KIDNEY AND PELVIS 185 

diseased kidney, as an atrophied kidney always is, can never void 
any salts. In those cases in which 'salts are present, though all 
the other features admit of a positive diagnosis of atrophy of the 
kidney, we can reach the conclusion that only one kidne}^ is as 
yet affected, since the salts must be voided by the other kidney. 
In such cases it will always be noticed that the constitution, 
although greatly impaired, can not as yet be called poor, since, 
though many pus-corpuscles are finely granular and pale, some 
will still show a moderately coarse granulation. The prognosis in 
all such cases is considerably better than when no salts whatever 
are seen. 

Chronic Croupous Nephritis, with Acute Croupous Recur- 
rence. — In many cases of chronic croupous nephritis, acute 
recurrences may occur at any time, and fresh portions of the 
kidney tissue become inflamed. Such acute recurrences can, in 
some individuals, be produced upon the slightest cause, as 
exposure to cold or errors in diet. It is not uncommon for a 
recurrence of this kind to be produced every few weeks or months, 
leaving the patient weaker every time, and finally resulting in 
death. 

A case of this kind, in which an acute croupous haemorrhagic 
recurrence took place in a young man of twenty years, is shown 
in Fig. 89. 

In this case, which ended fatally, all six varieties of casts, and 
of all three sizes, were present in large numbers. Not only were 
the regular casts seen, but a number of different combinations. 
The casts present were hyaline, epithelial, blood, granular, fatty, 
waxy, granular -fatty, epithelial -waxy, blood -waxy and fatty- 
waxy. 

Red blood-corpuscles were present in every field in moderately 
large numbers, and variously sized groups of fat -globules were 
also abundant. Pus -corpuscles were numerous, and epithelia 
from the convoluted as well as the straight collecting tubules of 
the kidney were present in large numbers, many studded with 
fat-globules. Connective-tissue shreds were present, and mucus in 
the form of threads, and especially casts, could be seen in many 
fields. Of the accompanying inflammations, the pyelitis was 
the most severe, though the inflammation of the ureters and 
bladder were well marked. 

Salts were entirely absent and the constitution was very poor, 
so that the diagnosis of probably both kidneys being affected in 




Fig. 89. Chronic Croupous or Parenchymatous Nephritis with Fatty and 
Waxy Degeneration of the Kidney and an Acute Hemorrhagic Croup- 
ous Recurrence, Catarrhal Pyelitis and Cystitis (X 500). 

RB, red blood-corpuscles ; PC, pus-corpuscles ; CE, epithelia from the convoluted tubules 
of the kidney; SE, epithelia from the straight collecting tubules of the kidney ; UE, epithelia 
from the ureter; PE, epithelia from the pelvis of the kidney; UB, epithelium from the upper 
layers of the bladder ; MB, epithelium from the middle layers of the bladder ; HC, hyaline 
cast ; EC, epithelial cast ; BC, blood cast ; GC, granular cast ; FC, fatty cast ; FW, fatty- 
waxy cast ; EW, epithelial-waxy cast ; CT, connective-tissue shred ; MS, mucus-thread; 
MC, mucus-corpuscle ; FG, free fat-globules. 

(186) 



DISEASES OF THE KIDNEY AND PELVIS 187 

a severe degree, and a bad prognosis, had to be given. The 
patient died within two weeks after the examination. 

From the descriptions here given, it will be seen that the 
casts fonnd in croupous or parenchymatous inflammations of 
the kidney will always show whether the process is acute, sub- 
acute, or chronic. When hyaline, epithelial, or blood casts are 
found in a case giving all the symptoms of chronicity, we 
can be certain either that an acute recurrence has taken place 
in the same kidney, or that the second kidney has become 
acutely inflamed. Sometimes cases of a so-called acute inflam- 
mation will show granular and even fatty casts in large num- 
bers, but careful questioning of the patient will bring out the 
fact that he has not been perfectly healthy for a long time, 
though he may have been able to attend to his business in 
spite of headache and general malaise. The only cases in 
which purely granular casts in small numbers may occasionally 
be seen two or three weeks after the commencement of the 
inflammation, are those already mentioned : in children after 
scarlet fever. Waxy casts will never appear in acute inflam- 
mations, but always denote chronicity. 

SUPPURATIVE NEPHRITIS 

Suppurative nephritis, also called abscess of the kidney, 
pyo- nephrosis, or surgical kidney, the most intense of the 
three primary varieties of nephritis, is an independent process, 
and must not be confounded with acute interstitial nephritis 
or pyelo- nephritis, as is frequently done. There may be either 
a number of small, disseminated foci of suppuration, or one 
large abscess, usually confined to one kidney. Sometimes the 
suppuration may be so excessive that the larger part of the 
structure of the kidney has disappeared, and a large, thick- 
walled cavity filled with pus is found in its place. 

Causes. — The causes of a pyo -nephrosis are not always plain, 
though in many cases the disease is the result of an exten- 
sion of the inflammatory process from some other portion of 
the genito- urinary tract. A simple gonorrhoea, which gradually 
extends upward, may be sufficient to cause it, and both ure- 
thral strictures and inflammation and hypertrophy of the prostate 
gland may be causes. The use of unclean sounds and catheters, 



188 URINARY ANALYSIS AND DIAGNOSIS 

even in these days of antisepsis, is not rarely followed by a 
pyo- nephrosis. 

Occasionally the disease follows different acnte infectious dis- 
eases, snch as typhus and typhoid fevers, cholera, and diph- 
theria, or may be seen with pyaemia and carbuncles. In reual 
tuberculosis, abscesses are quite common, and they may also 
occur when calculi are present. In still other cases the aetiology 
remains obscure, and we can only surmise that pyogenic organ- 
isms in large numbers have settled in a perhaps previously 
inflamed kiduey. 

Clinical Symptoms. — Acute abscesses are usually ushered in 
by pronounced chills, followed by a rise in temperature and gen- 
eral depression. Pain, as a rule, is present, although it is not 
always referred to the seat of the abscess. Emaciation, nausea, 
and vomiting can occur. After an abscess has ruptured, it may 
continue to discharge pus for a long time, becoming chronic. 
In these cases the acute symptoms gradually subside, though a 
slight fever is always present, and pain or tenderness either in 
the region of the kidney, or in the inguinal region, testicles, or 
legs, is a constant feature. 

Features Found in Urine. — The urine in pyo -nephrosis is 
always cloudy, and a pronounced heavy sediment invariably 
forms. The specific gravity varies considerably, but is mostly 
below normal, and the amount of urine is diminished. Albumin 
is present in large amount in every case. 

The clinical symptoms are at times so vague that a positive 
diagnosis is generally possible only through a microscopical 
examination of the urinary sediment. The features found under 
the microscope will at once clear up the diagnosis, and it does 
not seem necessary for the abscess to have ruptured ; emigrated 
pus -corpuscles and the shedding of connective -tissue shreds are 
sufficient for a diagnosis as long as no firm membrane has 
formed around the abscess. 

The microscopical features are the presence of an enormous 
number of pus -corpuscles, many kidney epithelia, usually from 
both the convoluted and. straight collecting tubules, and a 
varying number of red blood -corpuscles, the latter being very 
numerous in acute abscesses. Besides these, connective -tissue 
shreds are always found, either in moderate or large amount. 
Without such shreds, abscess of the kidney should never be 
diagnosed, since these alone show a destruction of the kidney 



DISEASES OE THE KIDNEY A3 1) EEL VIS 189 

tissue. Epithelia from the pelvis of the kidney almost invari- 
ably accompany the affection. Casts may be either present or 
absent ; when present, they denote a complicating- croupous 
nephritis. 

The features seen in a chronic suppurative nephritis are 
shown in Fig. 90. 

The pus -corpuscles are extremely numerous, and may so 
entirely fill some fields that no other features become visible. In 
other fields, however, epithelia from the convoluted tubules of 
the kidney will be found in large numbers, and, as a rule, 
those from tbe straight collecting tubules are also present. 
Fat -globules and -granules are abundant, partly lying free in 
variously sized groups, partly filling the pus -corpuscles and 
epithelia to a greater or less degree. Connective -tissue shreds 
are present, being large and abundant. 

Red blood- corpuscles are always found, but in such cases 
in small numbers only, while not infrequently rust -brown crys- 
tals of haamatoidin, in the form of needles and plates, but 
especially the former, denoting a previous haemorrhage, are 
seen. These will be found in the pus -corpuscles and epithelia, 
as well as free. In the case depicted, the hgematoidin crystals 
were very abundant, being found in the form of large con- 
glomerations of irregular, curved needles and stars, as well as 
smaller plates. Epithelia from the pelvis of the kidney, the 
ureter, and the bladder, denoting an inflammation of these 
organs, are also fairly numerous. In addition, numerous bacte- 
ria are usually present. 

Although these features are perfectly characteristic, we not 
infrequently find another, the so-called endogenous new-forma- 
tion of pus -corpuscles in the pelvic epithelia, denoting, if pres- 
ent in large numbers, a pressure upon the pelvis. Such a 
diagnosis will, therefore, hardly ever present any difficulties, 
contrary to the opinion frequently held that it is impossible to 
diagnose an abscess from the examination of the urine alone. 

Abscesses not directly in the kidney substance, but pressing 
upon the kidney — perirenal abscess, — may also be diagnosed. 
These will show the same features in the urine, though perhaps 
somewhat less marked, together with endogenous new-forma- 
tions in the kidney epithelia. Whenever these are seen in many 
epithelia, they are caused by long continued pressure upon the 
kidney, and will justify the diagnosis. 









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DISEASES OF THE KIDNEY AND PELVIS 191 

SUPPURATIVE PYELITIS 

An abscess may develop in the pelvis of the kidney instead 
of in the kidney proper. The causes of this will be the same 
as for pyo- nephrosis, though perhaps calculi will more fre- 
quently produce an abscess here than in the kidney proper. 
The symptoms do not differ from those of suppurative nephri- 
tis, and the exact location of the abscess can only be determined 
by microscopical examination of the urine (Fig. 91). 

In an acute suppurative pyelitis, red blood -corpuscles are 
always present in moderate or even large numbers, and pus- 
corpuscles are extremely numerous. The diagnosis can be made 
from the cuboidal and irregular pelvic epithelia, which in these 
cases are abundant, and may be found in groups. In such 
abscesses, epithelia from all the different layers of the pelvis 
will be present. These epithelia may vary considerably in size, 
and a few may be even as large as those from the middle 
layers of the bladder. There will, however, be no difficulty in 
diagnosing them, since these large epithelia are irregular, angu- 
lar, lenticular, or pear-shaped. Connective - tissue shreds are 
numerous, and without them no such diagnosis must be made. 

In all cases epithelia from the ureter, showing a secondary 
inflammation, are quite abundant, and in many of them endoge- 
nous new -formations of pus -corpuscles will be found. Epithelia 
from the convoluted tubules of the kidney need not necessarily be 
present in acute cases, but sooner or later a moderate number, the 
indication of an accompanying nephritis, will be seen ; here, too, 
endogenous new -formations can appear. Very soon a cystitis 
will develop, and the epithelia from the bladder accompany the 
other features. 

In a chronic abscess of the pelvis, the features will be the 
same as those described in suppurative nephritis, except that the 
comparative number of the pelvic and kidney epithelia becomes 
changed, the former being considerably more numerous than 
the latter. 

TUBERCULOSIS OF THE KIDNEY 

Although renal tuberculosis can undoubtedly exist as a pri- 
mary disease, it is comparatively rare, being most frequently 
associated with tuberculosis in other organs. It may result from 
an extension of the tubercular process from other portions of the 



D O ® J? ®<r*M @ Q 




Fig. 91. Acute Abscess of Pelvis of Kidney, or Acute Suppurative 
Pyelitis (X 500). 

RB, red blood -corpuscles ; PC, pus-eorpnscles j UE, epithelium from the ureter ; PE, epi 
tbelia from the pelvis of the kidney ; CT, connective-tissue shreds. 



(192] 



DISEASES OF THE KIDXEY AND PELVIS 193 

genitourinary tract. In the kidney we will generally find evi- 
dences of a chronic catarrhal or interstitial nephritis, though in 
rare cases a croupous or parenchymatous inflammation accompa- 
nies the tubercular process. The tubercular nodules in different 
portions of the kidney enlarge, and, after a time, usually break 
down, so that ulcers or abscesses are formed. 

Features Found in Urine. — The appearance of the urine is not 
characteristic in these cases ; the color is usually pale, and it is 
turbid and of a low specific gravity. The amount of urine is 
increased, and a small amount, sometimes only a trace, of albu- 
min is present. The sediment is slight, unless ulcers or ab- 
scesses have formed, when it is more profuse. 

The features under the microscope are at first those described 
in a chronic catarrhal nephritis, and later on give evidences of a 
destructive process, with the presence of connective -tissue shreds 
in varying amount. In most cases a pronounced cystitis is asso- 
ciated with the process, and not rarely ulcers will be formed in 
the bladder. Such a chronic ulcerative cystitis should always 
be looked upon with suspicion, as being possibly due to a 
tuberculosis. 

Whenever tuberculosis is suspected in the kidneys, and the 
evidences of a chronic interstitial nephritis are found in the 
urine, examinations for tubercle bacilli must be made. This is 
not infrequently a tedious process, as the bacilli are rarely pres- 
ent in large numbers ; yet the diagnosis can not be made with 
certainty without them. Repeated examinations of many drops, 
from urine taken at different times of the day, will never fail to 
reveal them. 

Too much stress can not be laid upon the constitution of the 
patient, as shown by the appearance of the pus -corpuscles, in 
such cases. As long as the larger numbers of the pus -corpuscles 
are coarsely granular and glistening, showing a good constitu- 
tion, the presence of tuberculosis is not probable. As soon, 
however, as the pus -corpuscles, or a large number, of them, are 
! pale and finely granular, showing a considerably impaired or 
I poor constitution, the existence of a possible tuberculosis must 
I not be lost sight of. Such a poor constitution, with the evi- 
I deuces of only a moderate catarrhal nephritis and cystitis, may 
I not infrequently be among the first suspicious signs of tubercu- 
! losis, even when the clinical symptoms are as yet only slightly 
pronounced. 

M 



194 URINARY ANALYSIS AND DIAGNOSIS 

II. ANOMALIES OF SECRETIONS 

Of great importance in the diagnosis of kidney lesions are the 
anomalies of secretion, under which term the conditions known as 
Lithcemia and Oxaluria are included. Sooner or later these will in 
many cases produce an inflammation of the kidney proper, as 
well as the pelvis of the kidney, and may in pronounced cases 
cause haemorrhages from the kidney and pelvis, as well as 
abscesses. 

Both lithaemia and oxaluria are of frequent occurrence, and 
need not of necessity lead to the production of calculi, though 
this may occur. Persons so affected will pass large quantities 
of uric acid or oxalate of lime, or both, and their urine almost 
invariably has a high specific gravity. 

Causes. — The causes of these conditions are practically un- 
known. It was believed that persons who live high, eat an 
excessive amount of meat as well as starchy and saccharine 
substances, and drink considerable champagne, are predisposed 
to the so-called uric acid diathesis. This is undoubtedly true 
in some cases ; but in others just the opposite conditions pre- 
vail, and still uric acid is voided in large amounts. 

Clinical Symptoms. — The clinical symptoms in these cases, 
which are much the same in both conditions, are headache, 
general malaise, dyspepsia, sleeplessness, neurasthenia, and later 
on melancholia. Pronounced pain is never present, but there 
is often a dull, aching feeling in the lumbar region. Persons 
so affected always sooner or later suffer from neurasthenia 
and melancholia, and may be treated for a variety of affections 
before the true cause of their condition is discovered. 

LITH^MIA 

The microscopical features in the urinary sediment of a per- 
son affected with lithsemia are quite characteristic (Fig. 92). 

Crystals of uric acid are found in large numbers, and as a 
rule all three varieties, — the common form, that seen in over- 
acid urine, and gravel from the pelvis of the kidney, — are 
present. The crystals may attain large sizes, but usually the 
smaller sizes only are met with. Besides these, crystals of 
oxalate of lime in moderate numbers are also present. In 
many cases which come under observation, pus -corpuscles are 
found in small or moderate numbers, as well as different epi- 



i 




j Pig. 92. Lith^mia, with Subacute Catarrhal Pyelitis and Cystitis (X 500). 

UA, uric acid crystals ; OC, oxalate of lime crystals ; RB, red blood-corpuscle ; PC, pus- 
I corpuscles ; PE, epithelia from the pelvis of the kidney ; UE, epithelium from the ureter; 
I UB, epithelium from the upper layers of the bladder ; MB, epithelium from the middle 
| layers of the bladder. 



(195) 



196 UBINARY ANALYSIS AND DIAGNOSIS 

thelia, more especially those from the pelvis of the kidney 
and the ureters, though epithelia from the convoluted tubules 
in small numbers and bladder epithelia are rarely absent. Red 
blood -corpuscles are not numerous when no haemorrhage has 
taken place, though a few are always seen. A few fat -globules 
are usually seen in the pus -corpuscles and epithelia. 

In these, the common cases of litkaemia, we have, therefore, 
an inflammation of moderate severity only, either a simple pyelitis 
or a pyelo- nephritis, with an accompanying cystitis. The in- 
flammation, when seen, is rarely acute, but usually subacute or 
chronic. Such a condition may go on for many years without 
producing any other features. 

When large numbers of these salts are continually produced 
and deposited in the pelves and calices of the kidneys, smaller or 
larger concretions or calculi will then be formed, and cause more 
pronounced symptoms. In such cases, the first symptom is not 
infrequently a haemorrhage from the kidney or pelvis, with more 
or less severe pain. The urine will show all the features of such 
a haemorrhage, together with concretions of uric acid. After a 
day or two all the symptoms may subside, but if the causes lead- 
ing to the formation of the salts still continue, will recur sooner 
or later. 

Haemorrhage from the Pelvis of the Kidney. — Haemorrhage 
from the pelvis of the kidney, due to uric acid calculus, gives 
characteristic features in the urine, from which the diagnosis can 
easily be made (Fig. 93). 

The field is crowded with red blood -corpuscles, which vary 
very considerably in shape, size, and appearance. As the urine is 
usually not examined until a number of hours after it is voided, a 
comparatively small number will be found containing haemoglobin, 
and are therefore of a yellowish or slightly brown color. The 
larger number usually have lost the haemoglobin, and these cor 
puscles will appear colorless, with a distinct double contour. They 
are found either singly or conglomerated in large groups. Cre 
nated red blood-corpuscles are frequently found, but in small 
numbers only, and they may also be seen edgewise. When they 
have imbibed water, they swell up, and may be even double their 
usual size. Again, a varying number of haematoblasts, which 
present the features of red blood- corpuscles, but are only half 
their size, are often seen in an active haemorrhage. White 
blood -corpuscles, which are twice the size of the fully formed 







Fig. 93. Hemorrhage from Pelvis of Kidney, Due to Uric Acid 
Calculus ( 500.) 

UA, uric acid crystals ; RB, red blood-corpuscles ; WC, white blood-corpuscle ; PE, epi- 
thelia from the pelvis of the kidney ; UE, epithelium from the ureter ; CT, connective- 
tissue shreds. 



(197; 



198 UBIXAET ANALYSIS AND DIAGNOSIS 

red blood- globules, and can not be distinguished from pus- 
corpuscles, are present in small numbers. They are always 
granular, either pale with a fine granulation, or more glistening 
and having a coarser granulation. When comparatively few of 
these corpuscles are seen, we know that they are not pus- cor- 
puscles, and their presence should never cause the diagnosis of an 
inflammation. 

Besides the blood-corpuscles, uric acid crystals, in the form of 
irregular plates, masses, and needles, are abundant. They vary 
considerably in size, are always colored, and may be either single 
or conglomerated. The needles may be seen in groups containing 
individual small formations, which sometimes appear like small 
granules, or they are large and form stellate masses. These are 
the characteristic forms from the pelvis of the kidney, which, 
when small, produce gravel ; when large, are portions of calculi. 

Epithelia from the pelvis of the kidney, varying in size but 
always characteristic, are more or less numerous. When the 
haemorrhage is severe, many fields may sometimes have to be 
examined before they are discovered, and the place of origin of 
the haemorrhage becomes clear ; but they are always present, often 
in groups of three, four, or more. Smaller epithelia from the 
ureter are also seen. Connective -tissue shreds are never absent. 
though their number and size may be small. In pronounced 
cases they are usually found in large numbers. 

Besides these features, variously sized masses of fibrin, in the 
form of thin, pale, often colorless strings, consisting of wavy 
bands, may sometimes be seen, and irregular clots of blood can 
also be found. In such haemorrhages, all the features, including 
the epithelia and connective -tissue shreds, may occasionally have 
a yellowish color from the haemoglobin ; but this is not the rule. 
unless the centrifuge has been used and the examination made 
immediately after the urine is passed. 

Pyelitis Calculosa.— In the so-called pyelitis calculosa, an 
inflammation or even suppuration of the pelvis is present, and 
due to calculi, the most common of which are uric acid and 
oxalate of lime, though phosphatic stones are also not rare. The 
features are the same as those found in any catarrhal or suppura- 
tive pyelitis, with the addition of concretions. Red blood- 
corpuscles are invariably present in such cases, but. unless a 
haemorrhage occurs iu the course of the inflammation, never in 
large numbers. 



DISEASES OF THE KIDNEY AND PELVIS 199 

OXALURIA 

Among the anomalies of secretion, oxaluria plays an im- 
portant part. It is far more common than is generally sup- 
posed, and in all cases giving vague neurasthenic symptoms, 
the urine should he examined. The specific gravity is usually 
high, not infrequently 1.030 or even 1.040, and the amount of 
urine passed does not vary much from the normal. The micro- 
scope always shows large numbers of crystals of oxalate of 
lime, in all shapes and sizes, and even in the milder cases an 
irritation of the pelvis of the kidney is rarely absent, so that a 
small number of pus -corpuscles and pelvic epithelia is found. 
Instead of a plain irritation, all the grades of inflammation may 
at different times exist, though oxaluria alone, without the pres- 
ence of a stone, will never cause suppuration. 

When many crystals are seen, minute concretions, which are 
so small as to give no special symptoms, are frequently passed, 
and these, in a few cases, may cause haemorrhages from the 
pelvis. In a number of cases, which have come under obser- 
vation, prolonged hgematuria existed, and the cause could not 
be discovered, as there was no pain connected with it, and 
no reason to suppose the presence of a calculus. Microscopical 
examination showed those minute concretions, and easily cleared 
up the case. 

HEMOGLOBINURIA 

Hemoglobinuria is a rare condition, which is characterized 
by a dissolution of the red blood -corpuscles, and the appearance 
in the urine of the coloring matters of the blood in solution. 
The red color of the urine which is always found in these 
cases is, therefore, not due to the presence of a large number 
of red blood -corpuscles, as in hgematuria, but to that of dis- 
solved haemoglobin. 

Causes. — The affection is occasionally seen after poisoning 
with different substances, such as carbolic acid, sulphuric acid, 
naphthol, muriatic acid, pyrogallic acid, and even chlorate of 
potash. It may occur in the course of severe infectious dis- 
eases, and is perhaps most common accompanying black vomit 
in yellow fever. After extensive burns, in scurvy, and purpura 
it has also been described. 

Besides these, it may occur as an idiopathic disease of inter- 



200 URINARY ANALYSIS AND DIAGNOSIS 

mittent character — the paroxysmal hemoglobinuria, — which is 
said to sometimes develop in rare cases of syphilis. In such 
cases urine containing haemoglobin may be voided either for 
a few hours only, or more rarely for days or even weeks, ac- 
companying symptoms much like those of intermittent fever. 
As a rule, attacks of this kind, follow exposure to cold. 

Features Found in Urine. — The appearance of the urine in 
haeruoglobinuria is always dark red or brownish, the sediment 
being abundant. The specific gravity varies considerably, but, 
as a rule, is slightly increased. Albumin will be found in vary- 
ing amount. Although the disease is by no means a distinct 
kidney affection, changes having taken place in the blood, a 
nephritis of varying degrees of intensity usually accompanies 
it, and its features will be found in the urine. 

The microscopical elements in a pronounced case of haemo- 
globinuria, which occurred in yellow fever, are illustrated in 
Fig. 94. 

The urinary sediment contains an extremely large number 
of dark or rather rust -brown masses, made up of granular 
matter, as well as granules scattered irregularly over the field. 
The masses vary considerably in size, some being small but 
others large, and may assume different shapes ; these are the 
masses and granules of haemoglobin. 

Haemoglobin is also found in the form of regular casts, 
which appear filled with dark brown granules, and differ from 
blood casts. The latter are rarely absent, though the blood- 
corpuscles are never found fully formed in the casts, but always 
disintegrated, and of a rust -brown color. Epithelial casts are 
frequently present and are also studded with haemoglobin. 

Red blood -corpuscles are never entirely absent in these cases, 
though they are comparatively scanty, and always, even in the 
freshly voided urine, appear very pale and double contoured, 
having completely lost their coloring matter. 

Besides these features, pus -corpuscles and epithelia are pres- 
ent, many of which are entirely filled with granules of haemo- 
globin and have a dark brown color. Pus -corpuscles are fairly 
abundant, and epithelia from the convoluted and straight col- 
lecting tubules of the kidney in moderate numbers. Epithelia 
from the ureters and the pelves of the kidneys are constant 
occurrences. 

Connective -tissue shreds are usually found, and may contain 




Fig. 94. HEMOGLOBINURIA, ACUTE HEMORRHAGIC CROUPOUS OR PARENCHYMATOUS 

Nephritis with Catarrhal, Pyelitis (X 500). 

RB, red blood-corpuscles ; PC, pus-corpuscle ; H, haemoglobin ; CE, epithelia from the 
convoluted tubules of the kidney ; SE, epithelium from the straight collecting tubules of the 
kidney; CEH, epithelia from the convoluted tubules filled with haemoglobin; PE, epithelia 
from the pelvis of the kidney ; HC, haemoglobin cast ; BC, blood east ; EHC, epithelial cast 
filled with haemoglobin ; CT, connective-tissue shred ; CH, cylindroid with haemoglobin ; 
OC, oxalate of lime crystals. 



;2oi) 



. : • UEJNABY ANALYSIS AND DIAGNOSIS 

some granules of haemoglobin npon them. Mucus in the form 
of threads or casts may be present, studded with masses of 
haemoglobin. In mo-" sases different salts, especially crystals of 
oxalate of lime, and uric acid crystals, are seen. In cases which 
have lasted a long time needles and plates of haematoidin 
may be found. 

CHYLrRlA 

Chyluria is characterized by the milky white appearance of 
the urine, similar to milk or to chyle : this appearance it 
retains on account of the molecular division of the fat which 
it contains, even if left standing for days. In some cases, 
though not in all, chylous urine has a pink tinge, due to 
the red blood- corpuscles frequently present. 

Two varieties of the affection are recognized : the first, or 
tropical form, occurs almost exclusively in hot climates, and is 
due to an invasion of the blood and urinary tract by a 
parasite — the Filaria sanguinis ~h.omin.is: the second, or non- 
fcropical form, is not due to a parasite, and is so rare that but 
little is known about it. 

In most cases chylous urine contains eoagula. due to a large 
amount of fibrin, which is usually present. These clots form in 
the bladder, and may be so abundant as to give rise to distress- 
ing symptoms when voided. 

The features of a chylous urine are illustrated :u Fig. 95. 
The case from which the illustration was drawn was recently 
seen by the author, and occurred in the practice of Dr. T. H. 
Allen, of New York. Its brief history is the following : 

Man. 33 years of age. a native of Porto Rico, has lived in 
the United Sfa fees for nine years. Three years ago he went to 
his native country for two weeks and then returned to the 
United States. Two months after returning, he noticed a milky 
appearance of his urine. The urine cleared up after a short 
time, and remained clear for more than two years, when it 
again became milky. The only symptoms he complained : 
when he first came under observation, were pain in the back 
and a slight frontal headache. In appearance, the patient was 
thin and delicate looking. ITpon physical examination nothing 
could be discovered except a slightly enlarged liver. 

Features Found, in Urine. — The appearance of the urine 




Fig. 95. Chyluria, Catarrhal Cystitis (X 500). 

FG, free fat-globules ; RB, red blood-corpuscles ; F, fibrin, with red blood-corpuscles and 
haematoidin-crystals ; FS, Filaria sanguinis ; PC, pus-corpuscle ; TJE, epithelium from the 
ureter ; MB, epithelia from the middle layers of the bladder ; CT, connective-tissue shred. 



203 



Z- TzzyjJST jjtaztsis jlsz zij.:-y:±:__ 



- i : z _ ~'zz:'z :._ 1 pink eoagrala were 
- I._- . :i "-:- _:.i:^:- _- z\ - -:lv varied in ^n, 

z'zr . _:_ — - z—g :-_"-! ::. ■■_ z'z- zzzzZr ~'_~'___ iizzenltr. Tney 
bad varikwnis sluapes r some resembling cysts. The* speeifie gravity 

— ; : .i 1 ' Z~. :lr -.-"""'_""_ >._i- "_"'.-" •.;•:■! \—i ~"_- z-.z.r :i_-;::::- r : 

Under tbe imkiueeope- Kb? dots proved to be masse a 

z . .._: ±i" - ' _- '. — ~li ' _ . . . ■■ rr= I:-'".".-:;-- 

:"_-« ~ -:- zzz__zz -~. — _ It— ■ .> " iziill pla.ci i "_ "e i: - - : : 1::: 
I _ - " - - . ; - z - _ ; . "_ " « - - ~ :_ f i:r:~ :•■' _:•:•!-:■: :•" ~ i- : 1 r> 

— r7-r ---- IZ.ZZZZZ -""--- '— _'l - ":i — -„ li ; — _ '. J £ ":rtLv 

of a TeOowiisIi color,, containing lttpmagiobin^ and partly color- 
less. Cremated red bfeood-eorpaseles m are present in moderate 

Besides tdtoese. niinmte fat-globules and -granules were 

-z~.rz_^.- „._„-_- rarrly ~ «z:Cr: :: ^-:r-: -_:.: — — : :._.--'- 

'-——^ ._-_".:." :!: _\ :~- :lr z-/ I" ■-_-.- :zA larger 

:• ~-i_ .-- - — -_ Iz - .- : ~_- - -z - - ~im - 

v^l: --O - - - -.- :lf- ~--- : izzz-jrz- -:z-- _- 

z- zzzz ' r. ;zz z z ~ - :zz - _- _ :z_ : : ;-.„"_.- ? zzz zz. - 

by r a mass of fat-gtoboks, was found. One small body, appa- 

The otber features "mere pos-eorposeles and epitbelia from 

-zzZZr ; "-- : -_- '.-■'/.--: :"-;-_-: ±e 

:_lf rZl~_Z.-rZ.Z- ~ t?t Z'.ZZZl 'ZZ r" rl~~ ..'V '.'. 

gamine a nnmber of drops before they were 

:->--.- jlreds — -: - :rese^: :!■:-*! ::■:■: in 




j"_~ 7~Ji 




- iii-^ ■■_■- /;"M ; "-/ 'zzz- :~~. i~ 

'•-i :■:■_-_ _„ zz~~ _- zzi: ~:1 I_- 

-1 .-- — _._- "_- _'■"--:. ~MeIi in 

: ?r_H '■".-. ""'"".".".-"_ - "Ian sar- 

i persons more advanced in y- 

f the kidney ean be positively made 

:- --_- ~~zz_r -_l'~ z •_:-. iiiil: 

ean bardly be made unth tbe 

:: :■: :> :___. :_t Z'.i>iirz 



DISEASES OF THE KID NET AXD PELVIS 205 

Clinical Symptoms. — When a malignant tumor has lasted for 
some time, the clinical features will become pronounced enough 
to at least suspect its presence, but in the early stages its symp- 
toms are not well defined ; though even at this time character- 
istic features may be found in the urine. Pain, referred either 
to the region of the affected kidney, or, less clearly defined, 
radiating to neighboring organs, will usually be the earliest 
symptom. It is mostly of a severe character, and may be 
paroxysmally increased. 

Very soon a tumor in the region of the kidney can be 
mapped out, the patient becomes anaemic and cachectic, and 
gradually loses strength. If not relieved by surgical procedures, 
the general symptoms become more pronounced, and the disease, 
as a rule, ends fatally within one or two years, although cases 
of sarcoma which have lasted four or five years are on record. 

Appearance of Urine. — The appearance of the urine is not 
characteristic. Since symptoms of inflammation soon develop, 
the specific gravity, color, and amount of urine voided will vary 
with the intensity of the inflammation. Haemorrhages, either 
constant or recurring at irregular intervals, soon appear, and 
the urine then has the pronounced reddish or brown color, due 
to the blood. Albumin is always present in varying amount. 

SARCOMA. 

Sarcoma of the kidney may be found in children as well as 
in adults, the youngest case seen by the author and diagnosed 
from the urine having been in a boy of four years, the oldest in 
a man of sixty-five years. Although the macroscopical appearance 
of the urine may vary considerably, the microscopical features are 
usually characteristic enough to admit of a positive diagnosis. 
In two cases the examination of the urine gave the first evi- 
dence of the disease, the clinical symptoms of the patient not 
being at first clear; by careful examination of the patient, how- 
ever, a tumor of the kidney could soon be mapped out, and 
further developments proved the correctness of the diagnosis. 

Features Found in Urine. — That sarcoma of the kidney can 
be diagnosed from the urine was first shown by Carl Heitz- 
mann, and a number of cases were published by him in the year 
1888. Since then other cases have been seen by the author, 
and autopsies have left no doubt of the correctness of his asser- 



•2':-: UBiyABT ANALYSIS JJST> DIAG1 TO&IS 

tions. In order to positively liagnose sarcoma, we must find 
large shreds of connective tissue, as well as numerous character- 
istic sarcoma corpuscles in the urine, and therefore an ulceration 
must have taken place. It is not impossible that these corpus- 
cles may appear in the urine before ulceration has set in, per- 
haps by emigration; but unless they are very numerous, a posi- 
tive diagnosis should not be given if large connective -tissue 
shreds are not found at the same time. It is well known that 
pus-corpuscles not only vary in size in different individuals, but 
also to a certain degree in the same individual, and that pus- 
corpuscles, which are as yet not fully formed, and appear as 
small, compact, -or vacuoled bodies, may be found. These should 
not be mistaken for sarcoma corpuscles. 

The features found in a urinary sediment in sarcoma of the 
kidney are depicted in Fig. 96. 

We see extremely large shreds of connective tissue, which 
in places appear more coarsely granular than usual, and may 
form regular coils in different portions. Occasionally these 
shreds will contain a small number of inflammatory corpuscles 
Besides the shreds, small, globular, coarsely granular, glisten- 
ing, even homogeneous corpuscles, without nuclei and having 
sharply denned contours, larger than red blood- corpuscles and 
smaller than pus -corpuscles, are found in large numbers ; these 
are the sarcoma corpuscles. They are not only found singly, 
scattered throughout the field, but in variously sized, sometimes 
large groups. These corpuscles are so different in appearance 
the larger, in th— r sases almost invariably pale pus- 
lscles, as to become noticeable at first glance. Being 
dements seen in the tumor, they will never appear in any 

Besides these feature — e find the evidences of a more or 
less severe inflammation, either with or without haemorrhage. 
In the case under consideration, red blood- corpuscles were not 
numerous, but pus -corpuscles were present in fairly large 
numbers, many containing fat -globules, showing chronicity. 
These pus-corpuscles were almost without exception finely gran- 
ular, and in some one or more nuclei were plainly visible, show- 
ing conclusively that the constitution was poor. Epithelia 
from the convoluted as well as the straight collecting tubules 
of the kidney, many containing fat -globules, were present in 
large numbers, and groups of free fat -globules were also quite 




Fig. 96. Sarcoma of Kidney, Chronic Catarrhal Pyelitis and 
Cystitis (X 500). 
RB, red blood-corpuscles; PC, pus-corpuscles; SC, sarcoma corpuscles ; CE, epithelia 
from the convoluted tubules of the kidney ; SE, epithelium from the straight collecting 
tubules of the kidney; UE, epithelia from the ureter; PE, epithelia from the pelvis of the 
kidney ; MB, epithelia from the middle layers of the bladder ; CT, connective-tissue shreds ; 
FG-, free fat-globules. 



207) 



208 URINARY AXALTSIS AND DIAGXOSIS 

abundant. Epithelia from the pelvis of the kidney could be 
seen, and in many of them the endogenous new -formation of 
pus -corpuscles, indicating pressure, were present. Epithelia 
from the ureter and the middle layers of the bladder com- 
pleted the features. 

Not infrequently a croupous nephritis may be present, and 
then casts, especially of the granular and fatty variety, will 
be found. 

CANCER 

In cancer of the kidney, a positive diagnosis can not be 
made so easily from the simple examination of the urine. 
When a large number of irregular connective -tissue shreds, 
containing inflammatory corpuscles, and perhaps also larger, 
coarsely granular, frequently multi -nuclear epithelia are found, 
together with all the evidences of a chronic inflammation, 
cancer can undoubtedly be suspected, and the clinical symp- 
toms will soon clear up the diagnosis. In rare cases, we may 
find regular cancer nests, similar to those described in cancer 
of the bladder. 



Chapter XV 
DISEASES OF THE BLADDER 

I. INFLAMMATIONS OF THE BLADDER 

According to the degrees of intensity, inflammation of the 
bladder— cystitis— may be divided into catarrhal, suppurative, 
and ulcerative. The inflammation may be either acute, subacute, 
or chronic, and may affect either small portions of the mucous 
membrane of the bladder only, or almost the whole. 

The pathological changes in catarrhal inflammation of the 
bladder are the same as those found in any mucous membrane, 
and have been described in the previous chapter. In severe 
inflammations ulcers may be formed, which may become quite 
extensive, and in rare cases even lead to perforation. Occa- 
sionally abscesses will form in the wall of the bladder. 

Causes. — The causes of a cystitis, which may be either pri- 
mary or secondary, are numerous. Primary cystitis may be due 
either to exposure to cold, to chemical irritation, or to traumata. 
That a simple exposure to cold may cause a cystitis, often quite 
severe in character, can not be denied. Among the chemical irri- 
tants different remedial agents, such as turpentine, copaiba, can- 
tharides, and strong mineral acids, may be mentioned. Alcoholic 
stimulants in large amount may cause mild attacks, as well as 
certain articles of diet, such as asparagus. 

One of the most common causes of cystitis is the passage 
into the bladder of instruments, such as catheters or sounds, 
which have not been thoroughly disinfected, so that pyogenic 
bacteria are introduced in large numbers. Again, traumata of 
different kinds are often responsible for the development of a 
cystitis. 

Secondary cystitis is at least as frequent as the primary form, 
and is often due to an extension of the inflammatory process 
from one or other of the genito- urinary organs. Gonorrhoea is 
a common cause of cystitis, in the first days of the disease as well 
as later on. Prostatitis, hypertrophy of the prostate gland, semi- 

N (209) 



210 URINARY AXALYSIS AXD DIAGNOSIS 

rial vesiculitis, vaginitis, cervicitis, and parametritis, as well as 
perimetritis, may all cause it. Again, inflammations of the blad- 
der in ay be produced by an inflammation of the kidney, pelvis, and 
ureter, the process gradually extending downward. Indeed, it is 
rare that a secondary cystitis, though mild in character, does not 
accompany a nephritis or pyelo- nephritis, even in acute cases. 
In chronic cases, such an accompanying inflammation is always 
present. 

That other affections of the bladder, such as tumors or ealcoJi 
in the bladder, will soon cause an inflammation, is evident. In 
many other diseases, such as the different infectious and con- 
tagious diseases, it may occur at any time. Retention of the 
urine must be looked upon as an important cause. 

In many cases, but not in all, micro-organisms in varying 
numbers will be present. In the mild acute cases, they may be 
absent entirely, or be present in small numbers only, while in the 
more pronounced cases they are always numerous. As a rule. 
both cocci and bacilli are found, though one or the other may 
predominate or even exist alone. The varieties of the micro- 
organisms which may be present in the bladder can not always 
be determined, since a number will undoubtedly be of secondary 
origin. Among the cocci, the different staphylococci — staphylo- 
coccus pyogenes aureus, albus. and citrous — as well as the strep- 
tococci pyogenes are common. The micrococcus urea? is often 
found in large numbers, and a variety of sarcina. called sarcina 
urina?, somewhat smaller than the usual form, is not rarely seen. 

Among the bacilli, the bacterium coli commune, the bacillus 
urea?, and the urobacillus liquefaciens septicus, occur. In some 
cases leptothrix threads are abundant. It has been claimed that 
the bacterium coli commune is more frequently found in cystitis 
than any other one bacillus, though the number of bacilli 
described is quite large. 

In the cases of so-called bacteriuria, bacteria of various forms 
may be present in enormous numbers in the bladder, and their 
origin can not always be determined. It is certain that bacteria 
alone will not cause cystitis, but when an irritation of some kind 
exists, they can set up a severe inflammation. The reaction of 
the urine does not necessarily need to be alkaline when micro- 
organisms have developed ; but on the contrary, some, as the 
bacterium coli commune, are frequently found with an acid 
reaction . 



DISEASES OF THE BLADDER 211 

Clinical Symptoms. — The symptoms seen in cystitis vary con- 
siderably with the severity and acuteness of the attack. An 
intense acute inflammation may be ushered in by chills, followed 
by moderately high fever, and all the concomitant symptoms of 
the same. In milder cases, fever will not be present. Frequent 
micturition invariably exists; this varies considerably with the 
intensity of the inflammation, and in the severe cases there is a 
constant desire to urinate, although only a few drops may be 
voided at a time. More or less intense pain is never absent. The 
pain may be most pronounced at or just before the beginning of 
micturition, be somewhat diminished during the flow of urine, 
and again become more severe at the end of micturition. At 
other times the flow of urine seems to increase the pain, which is 
diminished immediately after. A certain amount of pain or discom- 
fort almost invariably exists irrespective of urination, and may 
radiate to the back, thighs, scrotum, and penis. It may be most 
severe in the perinaeum. Pressure upon the bladder, as well as 
the passage of a catheter or other instrument, always causes 
more suffering. 

In chronic cases which are comparatively mild in character,, 
frequent micturition, sometimes not very pronounced, with a 
feeling of discomfort, may be the only symptom. When a 
cystitis has lasted for a long time the bladder becomes en- 
larged, sometimes to a great degree. In such cases, the bladder 
is never entirely emptied, and incontinence may exist, so that 
the urine will dribble away continually. 

Appearance of Urine. — The appearance of the urine varies. 
In the mild cases, when no bacteria are present, it may be per- 
fectly transparent, but as soon as bacteria in moderate or large 
numbers have developed it is more or less turbid. The specific 
gravity also differs, being normal in mild cases and increased or 
diminished in the severer forms. Albumin is never entirely 
absent in these cases, since it will always be found whenever pus- 
corpuscles are seen in the urine. In mild cases, however, no 
more than a trace, sometimes very faint, can be discovered, while 
in the more intense cases it may exist in large amount. The 
reaction of the urine may be acid or alkaline. In mild acute 
cystitis, even when a few bacteria are seen, it may be acid, 
though, as a rule, only slightly so. In chronic cases, on the other 
hand, the urine is always more or less alkaline, and the alkalinity 
may be marked. 



212 URINARY ANALYSIS AND DIAGNOSIS 

CATARRHAL CYSTITIS 

Microscopical Features. — The microscopical features in cys- 
titis differ in the acute and chronic cases, as well as with the 
intensity of the inflammation, and are always characteristic on 
account of the presence of bladder epithelia. Pus -corpuscles, 
epithelia from the bladder, and mucus - threads are never absent, 
though their amount differs in the different cases. 

Acute Catarrhal Cystitis (Fig. 97). — In an acute catarrhal 
cystitis of moderate severity the reaction of the urine may still 
be slightly acid, and salts will usually be found under the 
microscope, though they are not abundant. Those most com- 
monly seen are crystals of oxalate of lime of different sizes, 
present in almost every field. Even in these cases, however, 
which still give an acid reaction, a small number of globules 
of urate of ammonium, partly the dumb-bell form of urate of 
ammonium in statu nascenti, partly small, but fully formed 
globules, are seen. 

Pus -corpuscles are never absent, as without them, no diag- 
nosis of inflammation is possible ; but their number varies, and 
the mildest cases show perhaps only two, three, or four in 
every field. The more intense the inflammation, the more 
numerous are the pus -corpuscles. Red blood -corpuscles are 
present in every case of acute cystitis, and also vary in 
number to a great degree ; but unless haemorrhages have oc- 
curred, are never abundant. In haemorrhages, which are rare, 
and usually found only when the cystitis is due to calculi, 
tumors, parasites, or a severe trauma, the red blood -corpuscles 
may be so abundant as to obscure the other features. 

The diagnosis of a cystitis depends entirely upon the 
presence of the characteristic epithelia from the different 
layers of the bladder. As previously explained, the bladder 
has stratified epithelium, the different strata of which contain 
different epithelia. The upper layers are lined with flat, the 
middle with cuboidal, and the deepest covering, one layer 
only, with columnar epithelia. The flat epithelia are desqua- 
mated in perfect health, though to a small degree only, and 
when these are present alone in the urine, without any pus- 
corpuscles or cuboidal epithelia, the diagnosis of cystitis must 
never be made. As soon as the cuboidal epithelia are found, 
we can be certain of a pathological process in the bladder; 
the more pronounced, the more numerous they are. 




Fig 97. Acute Catarrhal Cystitis (X500). 

RB, red blood-corpuscles ; PC, pus-corpuscles ; O, oxalate of lime ; UA, urate of ammo- 
nium ; UB, epithelia from the upper layers of the bladder ; MB, epithelia from the middle 
layers of the bladder ; MS, mucus-threads ; MC, mucus-corpuscles ; €B, bacilli and cocci. 



(213; 






214 URINARY ANALYSIS AXI) DIAGNOSIS 

In an acute catarrhal cystitis, the flat epithelia from the 
upper layers and the cuboidal from the middle layers are 
always present together, and the more flat epithelia we find 
in comparison with the cuboidal. the milder the case. In 
such cases pus -corpuscles are scanty. "When the flat and 
cuboidal epithelia are present in equal numbers, the inflam- 
mation is not very severe, but when the cuboidal epithelia are 
more abundant than the flat, pus -corpuscles will also be more 
numerous and the inflammation is more intense. We do not 
expect to find columnar epithelia, unless the inflammatory pro- 
cess has extended to the deepest layer, and has become very 
pronounced. 

The sizes of the different epithelia vary in a small degree only 
in the different cases, therefore can always be diagnosed. Care 
must be taken not to mistake folded epithelia from the upper 
layers for columnar epithelia, which they sometimes resemble ; 
they are, however, somewhat more irregular, always paler, and 
more finely granular than those from the deepest layer. 

Mucus in the form of threads and corpuscles can be found 
in almost every case, and are more abundant in the severer 
inflammations. Mucus -threads are pale, and consist of fine, 
sometimes hardly perceptible fibers. They can never be mis- 
taken for connective -tissue shreds — which we do not expect 
to find unless the case is intense or haemorrhages occur, — since 
they are pale, finely striated, and the individual fibers usually 
run quite parallel. When large, mucus -threads may branch 
off and sometimes fill the greater part of the field. Besides 
the threads, mucus -corpuscles are also found in varying num- 
bers. Such corpuscles are pale, more or less irregular in out- 
line, finely granular, and never contain a nucleus. They may 
have the size of pus -corpuscles, but are often considerably 
larger. Even in the milder cases of cystitis the so-called 
cylindroids or mucus -casts — pale, delicate, striated formations, — 
can also be seen. 

The only other features which may be found in these cases 
are bacteria. Their number has little significance as to the 
severity of the inflammation, since even in severe inflammations 
they may be scanty, while they may be abundant in a mild case. 

Chronic Catarrhal Cystitis (Fig. 98).— In chronic catarrhal 
cystitis the reaction of the urine is usually alkaline, and the 
more pronounced it is, the more chronic is the case. The sedi- 



, 







Fig. 98. Chronic Catarrhal Cystitis (X 500). 

UA, urate of ammonium ; TP, triple phosohates ; SP, simple phosphates ; PC, pus- 
corpuscles ; MB, epithelia from the middle layers of the bladder, containing fat-globules ; 
MS, mucus-threads ; MC, mucus-corpuscles ; BC, bacilli and cocci ; PG, free fat-globules. 



(215) 



216 UJRINABY ANALYSIS AND DIAGNOSIS 

ment generally contains the different varieties of phosphates, 
both complete and incomplete triple, as well as star -shaped 
simple phosphates. Globules of urate of ammonium are often 
quite abundant. 

Pus -corpuscles vary in number according to the intensity of 
the inflammation, and in many small, glistening fat -granules 
and -globules will be found. Sometimes they contain dark 
brown granules of pigment. In the more intense cases, pus- 
corpuscles are numerous and are frequently swollen, hydropic, 
or disintegrated. In purely chronic cases, red blood -corpuscles 
are scanty or entirely absent. When acute recurrences or haem- 
orrhages ensue, they become considerably more numerous. 

Epithelia are always present in greater or less amount, but 
their relative numbers are somewhat different from those found 
in acute cystitis. While in the latter flat epithelia from the 
upper layers are quite abundant, they are either entirely absent 
in the chronic cases, or are seen in small numbers only ; this is 
one of the differential points of diagnosis. Epithelia from the 
upper layers, when present in large numbers, denote either an 
acute case, or an acute recurrence of a chronic inflammation. 
Cuboidal epithelia from the middle layers are always found in 
varying numbers, many containing fat -granules or -globules. 
Columnar epithelia from the deepest layer are seen in the 
severer cases only, and then in small numbers. Free fat- 
globules are always present. 

Mucus - threads and -corpuscles are constant features in 
chronic catarrhal cystitis. In cases having a highly alkaline 
reaction, the urine is ropy and a jelly-like, viscid mass is 
present, sometimes so pronounced as to compose the greater 
part of the sediment. A urine containing such masses always 
has an ammoniacal odor, and the alkaline salts are extremely 
numerous. Besides the salts and bacteria, such a jelly-like 
mass consists of strings of mucus, sometimes filling entire fields 
of the microscope. In many of these cases, neither pus-corpus- 
cles nor epithelia can be recognized to any great degree, having 
become hydropic, pale, and apparently changed to mucus -cor- 
puscles. The appearance of a urine containing such masses is 
so characteristic to the naked eye that a diagnosis of chronic 
cystitis can, in many cases, be made without a microscopical 
examination. Bacteria are never absent in chronic inflamma- 
tions, and are usually abundant. 



DISEASES OF THE BLADDER 217 

Subacute Catarrhal Cystitis. — The features found in a sub- 
acute catarrhal cystitis are a moderate number of red blood- 
corpuscles, pus -corpuscles, as a rule not abundant, a few 
epithelia from the upper layers of the bladder, a moderate 
number from the middle layers, a few fat -globules, and a 
moderate amount of mucus. The reaction, in such cases, is 
usually slightly alkaline. 

ULCERATIVE CYSTITIS. 

The development of ulcers in the bladder is not rare, and 
traumata of different kinds are perhaps the most frequent 
causes. With the presence of calculi and parasites in the blad- 
der, but especially tuberculosis in any part of the gen ito -urinary 
tract, ulcerative cystitis is of common occurrence. In pro- 
nounced cases, such a urine has an intensely putrescent odor, 
and is very turbid. 

Microscopical Features — Acute Ulcerative Cystitis (Fig. 99). 
Under the microscope the features of an acute ulcerative cystitis 
are the following: 

The number of pus -corpuscles varies considerably, and they 
are not necessarily abundant. Red blood -corpuscles are always 
fairly numerous, and in many cases regular haemorrhages exist. 
Epithelia from the bladder are abundant, and present from all 
three layers; the columnar epithelia from the deepest layer, usu- 
ally absent in catarrhal inflammation, are often just as abundant 
as those from the middle layers. 

Connective -tissue shreds are found in large numbers, some 
of the shreds being large, while others are only of small size. 
These shreds are highly refractive, and consist of wavy, irregular 
fibers. The difference between them and mucus -threads, which 
are also present in varying numbers and are much paler than 
the former, is plain. 

Bacteria are numerous in all these cases, and zoogloea masses 
are invariably found. These masses are often large and numer- 
ous, and are never seen to such an extent in simple catarrhal 
cystitis. Their diagnosis is easy, and when large groups are 
present around connective -tissue shreds, in fresh urine, the exist- 
ence of an ulcer is almost certain. The salts vary considerably 
in amount in acute cases, and at. times they are found in 
small numbers only. 




Fig. 99. Acute Ulcerative Cystitis | X •- - 

RB, red blood-corpuscles ; PC, pus-corpuscles ; UB, epithelia from the upper layers :: 
the bladder ; MB, epithelia from the middle layers of the bladder : DB, epithelia from the 
deepest layer of the bladder; CT, connective -tiasn a sbrods; ilC, mnens-ilnpeads 

Z. zoOgloea-masses. 



(218) 



DISEASES OF THE BLADDER 219 

Chronic Ulcerative Cystitis (Fig. 100). — Alkaline salts, 
especially phosphates, are abundant. Pus -corpuscles are present 
in moderate number, but red blood -corpuscles are usually scanty. 
Epithelia from the upper layers of the bladder are either 
entirely absent or scanty, though transitional epithelia may be 
found. Cuboidal and columnar epithelia are abundant, the latter 
being often quite as numerous as the former. Fat -globules and 
-granules, both in free groups and in the pus -corpuscles and 
epithelia, are always seen. Connective -tissue shreds are just as 
abundant as in acute cases, while mucus- threads and -corpuscles 
are more numerous. Zooglcea masses are never absent, and 
may attain large sizes. Other bacteria are also found in large 
numbers. 

When the diagnosis of a chronic ulcerative cystitis has 
become clear from the above features, and the constitution is 
greatly impaired, as seen by the finely granular pus - corpuscles ; 
when, furthermore, no evidences of calculi or parasites are 
found, an examination for tubercle bacilli should always be 
made. In a number of cases, where the clinical symptoms were 
vague, but an ulcerative cystitis was present, examination for 
tubercle bacilli revealed the existence of a tuberculosis in the 
urinary tract, and at once cleared up the case. 

In one case, which was examined by the author, the ulcera- 
tive cystitis was produced by actinomyces. The urine contained 
a number of small granular masses, apparent to the naked eye, 
and upon examination these were found to consist of the char- 
acteristic club-shaped conglomerations of actinomyces, previously 
described. 

SUPPURATIVE CYSTITIS. 

Suppurative cystitis is comparatively rare. The diagnosis 
can be made if pus -corpuscles are numerous and epithelia from 
the different layers of the bladder abundant. Connective -tissue 
shreds are always present and red blood -corpuscles quite numer- 
ous. In such cases, bacteria will be seen in larger numbers, 
but the zooglcea masses, which are found in every case of 
ulcerative cystitis, are not present, or, if so, not pronounced. 
The differential diagnosis between an abscess and an ulcer must, 
however, be made chiefly from the comparative numbers of 
pus -corpuscles, which in an abscess are considerably more 
abundant. 







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DISEASES OF THE BLADDER 221 

PERICYSTITIS 

When an inflammation is present aronnd the bladder, instead 
of in the wail of the bladder proper, and pressure is exerted 
upon that organ, the epithelia from the middle layers of the 
bladder will show changes in a pronounced degree, which have 
been previously alluded to as endogenous new -formations. Such 
changes will occur when parametritic exudates exist, pressing 
upon the bladder, when a tumor is present either in the neigh- 
borhood of the bladder or in the wall of the bladder, or even 
simple extravasations of blood in the wall of the bladder may 
cause them. Pressure of anj* kind, no matter how slight, if 
continued for some time, such as pressure of the uterus upon the 
bladder, or of the prostate gland on account of hypertrophy of 
that organ, or inflammations of the seminal vesicles, will all 
produce such changes. 

In simple catarrhal cystitis a small number of epithelia from 
the middle layers may be found, containing a number of nuclei 
or even newly formed pus -corpuscles. So long as these forma- 
tions are scanty, they may be produced by the inflammatory 
process alone, a fact which has been known for many years. As 
soon, however, as the epithelia become irritated through pressure 
of some kind, the endogenous new-formation of pus -corpuscles 
in the desquamated cuboidal or columnar epithelia is very abun- 
dant. One epithelium may contain from two to four or even 
six such pus -corpuscles, or, instead of them, vacuoles may be 
seen, or pus -corpuscles and vacuoles in varying numbers. 

The features found in a case of pericystitis due to a para- 
metritis are shown in Fig. 101. They are the following : 

Pus -corpuscles are present in rather large numbers, and red 
blood -corpuscles are fairly numerous. Cuboidal epithelia from 
the middle layers of the bladder are abundant, and in every one 
the endogenous new -formation is plainly visible ; smaller cu- 
boidal epithelia from the ureters are present in moderate num- 
bers, some of which also contain endogenous new-formations. 
In a few of the pus -corpuscles and epithelia fat-globules are 
seen, and small groups of free fat-globules are also found. 
Mucus -threads are abundant and large, while connective -tissue 
shreds are scanty and small. 

Besides these features, ciliated columnar epithelia from the 
mucosa of the uterus and larger irregular epithelia from the 




Fig. 101. Pericystitis (X 500). 

RB, red blood-corpuscles ; PC, pus-corpuscles ; MB, epithelia from the middle layers of 
the bladder, with endogenous new-formations ; UE, epithelia from the ureter, with endogenous 
new-formations ; UtE, epithelia from the mucosa uteri ; CE, epithelia from the cervix uteri ; 
UV, epithelia from the upper layers of the vagina ; MV. epithelia from the middle layers of 
the vagina ; MS, mucus-threads : CT, connective-tissue shred ; FG-, free fat-globules. 



(222) 



DISEASES OF THE BLADDER 223 

cervix uteri are seen, as well as those from the upper and middle 
layers of the vagina, which, with the pus -corpuscles, are suffi- 
cient evidences of an endometritis, cervicitis, and vaginitis. 

II. TUMORS OF THE BLADDER 

Although many different varieties of tumors may occur in 
the bladder, the most common, and those which can frequently 
be diagnosed from an examination of the urine, are benign papil- 
loma and malignant sarcoma and cancer. Myoma is a rare tumor 
in the bladder, but when present can also be diagnosed, if parti- 
cles of the tumor appear in the urine. As long as no ulceration 
has taken place, the presence of a tumor of any kind can only 
be suspected ; but as soon as ulceration has set in and particles 
of the tumor are found in the urinary sediment, the diagnosis 
becomes positive. 

Clinical Symptoms. — In all tumors of the bladder, benign as 
well as malignant, one of the first, if not the first, and most 
pronounced symptoms is haematuria, mild in character only at 
the commencement, and occurring at long intervals, but later 
becoming more pronounced and more frequent. This haematuria 
may take place at any time, and is just as common during rest 
as when the patient is active. Besides the haematuria, pain is 
present in many cases, but not in all, being more frequent in 
malignant than in benign tumors, and radiating to the peri- 
naeum, the thighs, and the scrotum. In benigu growths, pain, 
if present at all, is rarely pronounced. Frequent micturition 
may exist quite early in the disease, and becomes more pro- 
nounced in the later stages. 

Malignant tumors sooner or later will cause general symptoms,, 
and, as a rule, end fatally in the course of one or two years, 
although cases of undoubted sarcomata have been known to last 
for four or five years. 

None of the symptoms here given are at all characteristic, and 
microscopical examination of the urine must be relied upon for a 
positive diagnosis. Tumors of the bladder may occur at all ages, 
a case of papilloma having been diagnosed by the author from the 
urine of a child of one year. 

PAPILLOMA 

Microscopical Features. — The microscopical features in a case 
of papilloma of the bladder are illustrated in Fig. 102. 



224 URIXAEY AXALYSIS AXD DIAGXOSIS 

Since haemorrhage is of such common occurrence in these 
tumors, red blood -corpuscles are usually present in the urinary 
sediment in large numbers. These may be irregularly scattered 
throughout the field, or are found conglomerated in groups, partly 
yellowish, containing haemoglobin, but at the time of examination 
mostly colorless, with the characteristic double contours. In 
cases of active haemorrhages, haematoblasts, having the appear- 
ance of red blood -corpuscles, but only half their size, may be 
abundant. If the latter contain haemoglobin, so that the double 
contour is not seen, care must be exercised not to mistake them 
for fat- globules, or even conidia ; they may be found in large 
groups as well as singly, between the regular -sized blood- 
corpuscles. 

The characteristic features of a papilloma are peculiar connec- 
tive-tissue shreds, which, as a rule, are abundant. Although 
variously sized shreds, not differing in any respect from those 
generally seen in the urine, are present, the larger numbers have 
an entirely different appearance. They are long, or extremely 
irregular, frequently branching in different directions, and often 
assume the shape of coils or knobs. Such shreds are coarsely 
granular, and not infrequently contain a number of inflammatory 
corpuscles. Again they may be found studded with fat -globules 
of different sizes, some of these being quite large. In rare cases, 
blood-vessels, either in process of formation or fully formed, 
some of considerable size, may be contained in them. 

The forms in which connective -tissue shreds may be found in 
the urine when a papilloma exists are sometimes so peculiar that 
a diagnosis can only be made when smaller and more regular 
shreds are found. In one case, it seemed at first glance as if 
large parasites of an unknown nature were present, but a more 
careful examination showed large knobs and coils, in which capil- 
lary blood-vessels, filled with blood -corpuscles, were seen coursing 
in various directions. The individual fibers of such shreds may 
have entirely disappeared, and the wmole shred appears as a mass 
of coarsely granular protoplasm ; these shreds might well be 
termed protoplasmic outgrowths of connective tissue. The more 
common varieties of connective -tissue shreds found in papilloma 
are shown in the illustration. 

In all cases of papilloma, epithelia from the different layers of 
the bladder, more especially the cuboidal and columnar varieties, 
are quite abundant, and usually are more or less studded with fat- 




Fig. 102. Hemorrhage from the Bladder, Due to Papilloma 
of Bladder (X 500). 

RB, red blood-corpuscles; H, heematoblasts ; PC, pus-corpuscles; MB, epithelia from the 
middle layers of the bladder, containing fat-globules ; DB, epithelia from the deepest layer 
of the bladder; PE, covering epithelia of papilloma; UB, epithelium from the upper layers 
of the bladder ; PCT, connective-tissue shreds from papilloma ; CT, connective-tissue shred ; 
FG, free fat-globules. 



(225) 



226 UBINABT ANALYSIS AND DIAGNOSIS 

globules, which latter are also seen in small groups. Many of 
the bladder epithelia contain the endogenous new -formations. 
Besides these, irregular, coarsely granular epithelia, with endog- 
enous new-formations — the covering epithelia of the papilloma, — 
are also present. These have the size of bladder epithelia, though 
they are always irregular, and are not characteristic of the 
papilloma. In none of the cases were the epithelia found 
adherent to the connective -tissue shreds, and care must be taken 
not to attempt a diagnosis of a tumor from these epithelia alone. 
In every case of papilloma, pus -corpuscles are present. They 
vary in amount with the intensity of the accompanying inflamma- 
tion, which, though never absent, differs in degree in different 
cases. As a rule, the pus -corpuscles have a moderately coarse 
granulation, if the tumor has remained local, and produced no 
secondary nephritis, showing that the constitution of the patient 
is fairly good. In rare cases, enormous masses of fibrin are 
found in the urine — regular fibrinuria. Mucus -threads are always 
present, though the other features may render them indistinct. 

SARCOMA 

As has been described in the previous chapter, a sarcoma can 
be diagnosed from the urine, when present in any part of the 
genito- urinary tract. Sarcomata of the bladder, although not 
common, undoubtedly occur. As in all tumors of the bladder, 
haemorrhages are frequent in sarcoma, and when the urine is 
examined during an attack of haemorrhage, the diagnosis becomes 
more difficult, since no such characteristic connective -tissue shreds 
as in papilloma are here found. 

Microscopical Features. — If blood -corpuscles are present in 
moderate numbers only at the time of the examination, the other 
features are distinct enough, and groups of small, glistening, 
frequently homogeneous, non- nucleated corpuscles, larger than 
red blood -corpuscles, but smaller than pus -corpuscles, are found 
in large numbers. These corpuscles, resembling lymph -cor- 
puscles, are the elements characteristic of a small, round -celled or 
lympho- sarcoma. Connective-tissue shreds must, however, always 
be seen before the diagnosis becomes positive ; these shreds may 
attain large size, and frequently contain inflammatory corpuscles. 
In most cases they do not differ from the shreds commonly found 
in urine, except by their large size. 



DISEASES OF THE BLADDER 227 

The other features seen in a sarcoma of the bladder are the 
same as those seen in every severe subacute or chronic catarrhal 
or ulcerative cystitis, epithelia from the deepest layer of the 
bladder being rarely absent. Many epithelia will contain endog- 
enous new -formations, and these are not infrequently seen in the 
accompanying epithelia from the ureters. Pus -corpuscles and 
fat -globules in varying numbers, together with mucus -threads, 
complete the features in these cases. 

CARCINOMA 

The varieties of cancer developing in the bladder are prin- 
cipally the villous, the epithelial, and the medullary, the first 
two being more common than the third. Villous or papillary 
cancer, the so-called cauliflower growth, is probably due in 
many cases to a secondary malignant change of a previously 
benign papilloma. This can be proved in those cases in which 
a tumor, having lasted for years and having always given the 
characteristics and features of a benign papilloma, becomes 
changed and assumes the features of malignancy. Such a vil- 
lous cancer is in reality only a subvariety of an epithelial 
cancer or epithelioma, but seems to be more frequently seen in 
the bladder than the regular epithelioma. Medullary cancer, 
perhaps the most malignant, that is, most rapidly fatal of all 
cancers, does not often develop in the bladder, and if it does, 
can hardly be distinguished by an examination of the urine, 
unless large masses of the tumor are cast off. 

Microscopical Features. — The features found in a urinary 
sediment of a case of villous cancer are depicted in Fig. 103. 

At the time this urine was examined, no active haemorrhage 
was taking place, therefore red blood -corpuscles were not 
numerous, though some were present. In different fields, 
variously sized, dark brown or even black blood -clots were 
seen, composed of masses of disintegrated blood -corpus- 
cles. Haematoidin crystals, in the form of small plates and 
needles, the latter also seen in small conglomerations, were 
present, though not abundant. 

The connective -tissue shreds found in villous cancer may be 
even larger and more irregular than those seen in papilloma, 
not infrequently having the appearance of cauliflower -like ex- 
crescences, or containing large bulbs or knobs. These shreds 






228 UEIXAEY AXALYSIS AND DIAGXOSIS 

are always coarsely granular and filled to a greater or less 
degree with inflammatory corpuscles, more pronounced than in 
papilloma. Again, a number of these shreds contain large, 
irregular cancer epithelia, sometimes even small nests, a feature 
never found in the connective tissue from a papilloma. Capil- 
lary blood-vessels, filled with blood -corpuscles, are sometimes 
found in these shreds, and may pervade their entire length. 

The original fibrous structure of the connective -tissue shreds 
has become changed, and only scanty fibers are present, the 
shred frequently appearing as a mass of coarsely granular 
protoplasm. Connective -tissue masses with a pronounced epi- 
thelial covering may perhaps occur in the urine in rare cases, 
but the detached masses from the tumor are usually changed, 
being broken down more or less completely, so that an epi- 
thelial covering is rarely seen. 

Besides the epithelia from the middle and deepest layers of 
the bladder, containing fat -globules and endogenous new-forma- 
tions, large numbers of irregular, coarsely granular epithelia, 
partly single, partly in groups, are present; these also contain 
fat -globules and endogenous new -formations, and are the cancer 
epithelia. As long as these epithelia are seen alone, without 
other evidences of cancer, no diagnosis of a malignant tumor 
can be made, since they can not be differentiated from other 
epithelia, as, for instance, those found in papilloma. In pro- 
nounced cases of cancer, however, variously sized epithelial 
nests are seen, containing three, four, or more cancer epithelia, 
and as soon as these are found the diagnosis of a cancer 
becomes positive, even though the connective -tissue shreds 
should not be as characteristic as above described. Pus-cor- 
puscles are always present in moderate or large numbers. 

Not only can a villous cancer be diagnosed, as just described, 
but also a regular epithelioma. In such cases the urine may 
contain epithelial masses showing a pronounced concentric ar- 
rangement, and even the fatty degeneration of the epithelia in 
the center, producing shining, irregular masses of fat, — the 
so-called cancer pearls, — may be present. All the other fea- 
tures will remain the same. 

The positive diagnosis of medullary cancer from the exam- 
ination of urine is not so easy, though the presence of a 
cancer of some kind can, as a rule, be made from features 
similar to those described. 




Fig. 103. Villous Cancer of the Bladder (X 500). 

RB, red blood-corpuscles ; PC, pus-corpuscles ; UB, epithelia from the upper layers of 
the bladder ; MB, epithelia from the middle layers of the bladder, containing fat-globules 
and endogenous new-formations ; DB, epithelia from the deepest layer of the bladder ; 
CE, cancer epithelia ; CN, cancer nest ; CT, connective-tissue shreds ; H, haematoidin crystals ; 
BC, blood-clot ; FG, free fat-globules. 



(229) 



230 URINARY ANALYSIS AND DIAGNOSIS 

When a tumor in the bladder has existed for some time, 
secondary inflammations of the ureter, the pelves of the kid- 
neys, and the kidneys frequently develop sooner or later, and 
may become pronounced. In the kidney, both catarrhal or 
interstitial and croupous or parenchymatous inflammation may 
appear. The urine will then show all the features of such an 
inflammation, in addition to those of the tumor. In the case 
of a child one year of age, in which a papilloma of the bladder 
existed, all the features of a subacute croupous nephritis were 
also found, and the case proved fatal in a short time. 

III. PARASITES IN THE BLADDER 

That a large number of micro-organisms of different kinds 
may not infrequently be found in the bladder, has already been 
mentioned. Symptoms of a more or less pronounced cystitis 
will sooner or later appear in almost all those cases. 

Animal parasites are also occasionally found in the bladder, 
among these being echinococci, actinomyces, distoma licemato- 
bium, and filaria sanguinis, as well as ascaris Imnbricoides, 
strongylus gigas, and oxyuris vermicularis. The diagnosis of 
these parasites is only possible when either their ova or the 
parasites themselves can be discovered in the urine. Many of 
these will invade the bladder only secondarily, being present 
in other organs, as the kidney or pelvis, or find their way 
into the bladder through the urethra. 

In every case of this kind, either haemorrhage or inflam- 
mations of varying degrees of intensity will sooner or later 
develop, with all the characteristic features in the urine. 
Ulcers are often due to such parasites, as, for instance, in the 
case of actinomycosis of the bladder previously mentioned. 



Chaptee XVI 
DISEASES OF THE SEXUAL ORGANS 

Diagnosis of diseases of the sexual organs by microscopical 
examination of the urine must of necessity be limited ; it is not 
of so great practical importance as in diseases of the urinary 
organs, since the clinical symptoms are in many cases sufficiently 
clear. There are, however, cases where the examination of the 
urine will either corroborate a suspected diagnosis, or will even 
lead to the clearing up of the case when the clinical symptoms 
are not plain. This will naturally be of more common occur- 
rence in diseases of the male than of the female tract, in 
which latter, examination of the patient is, as a rule, sufficient 
for the diagnosis. 

In the male, inflammations of the urethra, the prostate gland, 
and the seminal vesicles can be diagnosed from urine examina- 
tion, while in the female those of the vagina are easily diagnosed, 
and sometimes also those from the cervix of the uterus and the 
uterine mucosa. 

URETHRITIS 

Acute Urethritis. — The clinical symptoms of an acute 
urethritis, whether gonorrhceal or non-gonorrhoeal, are so evi- 
dent that an examination of the urine is never required to clear 
up the case. When it is examined for other purposes at the 
time such a urethritis is present, large numbers of urethral epi- 
thelia are always found. In the first days of a urethritis the 
irregular, flat epithelia from the upper layers are more abun- 
dant, but soon the cuboidal and columnar epithelia are, seen. 
Pus -corpuscles are present to a varying degree in every case. 

Chronic Urethritis. — The symptoms of a chronic urethritis, 
especially when of a mild character, may be so slight that the 
urine has to be examined to render the diagnosis certain. 

In many of these cases conglomerations of mucus with pus- 
corpuscles and epithelia — the so-called gleet - threads — are found, 
even though they are scanty. Under the microscope these 

(231) 



232 URINARY ANALYSIS AND DIAGNOSIS 

threads (Fig. 37) consist of a varying amount of mucus, both 
fibers and corpuscles, from the mucous glands of the urethra, 
pus -corpuscles, which are abundant in the more pronounced, but 
may be quite scanty in the mild cases, and urethral epithelia, 
which also vary in number. Besides these features, epithelia 
from the prostate gland are almost invariably present, and are 
usually more numerous than the urethral, which latter may at 
times not be found at all. The larger numbers of pus -corpuscles 
and epithelia are seen studded with small fat -globules, and these 
may also be seen upon and between the mucus -threads. If gleet- 
threads are not present, a small number of the irregular urethral 
epithelia, with pus -corpuscles, mucus -threads, and prostatic epi- 
thelia, are seen in every case of chronic urethritis. 

When an ulceration or stricture exists in the urethra, the 
urine, as a rule, shows some features. In an ulceration, red 
blood -corpuscles in at least moderate numbers, pus -corpuscles, 
bacteria — especially the zooglcea masses — urethral epithelia, mostly 
the cuboidal and columnar varieties together, and connective - 
tissue shreds are never absent. As the prostate gland almost 
invariably becomes involved in these cases, prostatic epithelia are 
also present. 

In stricture of a mild character, small connective -tissue shreds, 
with a few epithelia from the urethra and prostate gland, and a 
few pus -corpuscles, are not infrequently seen, although there may 
be no features whatever in the urine of such cases. The urethral 
epithelia may have two or even more nuclei. 

PROSTATITIS 

The diagnosis of a prostatitis from the urine is undoubtedly 
of greater importance than that of a urethritis, since, especially 
in the mild chronic cases, the clinical symptoms may not be 
sufficiently pronounced. 

Causes. — The causes of a prostatitis are numerous, though 
probably the most frequent cause of an acute inflammation is an 
acute urethritis. The passage of unclean instruments, such as 
sounds or catheters, injections of chemical agents, or any irritant 
or injury of whatever kind, such as may be due to horseback or 
bicycle riding, may cause a prostatitis, as well as simple exposure 
to cold and wet. In the course of febrile diseases it also develops 
occasionally. 



DISEASES OF THE SEXUAL ORGANS 233 

Chronic prostatitis may be produced by stricture of the ure- 
thra, masturbation, excesses in venery, haemorrhoids, constipation, 
or by inflammations of the neighboring organs. 

Clinical Symptoms. — An acute prostatitis, if severe, may be 
ushered in by chills and fever, followed by discomfort or pain in 
the perineal region and frequent micturition. The pain is usu- 
ally increased upon motion, and the perinaeum is found to be 
sensitive upon pressure. 

In chronic prostatitis the symptoms maj* be slight, the prin- 
cipal one perhaps being the occasional discharge of a small 
amount of a clear, viscid fluid, constituting the so-called prosta- 
torrhcea ; this flow is usually increased upon defecation. Besides 
this, slight discomfort and tenderness in the perinaeum, frequent 
micturition, and slight pain at the end of urination, may be 
present. Enlargement of the gland may cause more or less 
retention of urine. 

Features Found in Urine. — The appearance of the urine varies 
considerably with the intensity of the inflammation, and is not 
characteristic. In acute cases slight or more pronounced haemor- 
rhages may take place, and cause the urine to assume a darker 
color ; when considerable pus is present it will be more or less 
turbid, and also contain a varying amount of albumin. In mild 
chronic cases the urine may be perfectly clear. 

When such a urine is examined for albumin, it must not be 
forgotten that whenever pus -corpuscles and red blood -corpuscles 
are present albumin will always be found, its amount depending 
upon the amount of pus and blood, so that in cases of abscesses 
or haemorrhages the urine will contain considerable albumin, and 
faint traces will never be absent when there is any inflammation 
of the prostate gland. It is evident, therefore, how important a 
microscopical examination of the urine becomes in all these 
cases, since such an examination alone will determine whether the 
kidneys are inflamed, and this be the source of albumin, or 
whether the albumin is due simply to the prostatitis. 

Acute Prostatitis. — In an acute prostatitis of moderate sever- 
ity, the features found in the urinary sediment are red blood- 
corpuscles in varying numbers, pus -corpuscles, mucus, and 
epithelia from the prostate gland. Red blood -corpuscles are 
uever absent in an acute inflammation, and are numerous when 
haemorrhages occur, as is sometimes the case. Pus -corpuscles 
vary in number according to the degree of intensity of the 



234 URINARY ANALYSIS AND DIAGNOSIS 

inflammation. Mucus, in the form of threads and corpuscles, 
is always increased, and may be present in large amount. 

The characteristic features of a prostatitis are the epithelia. 
The prostate gland is lined by several layers of cuboidal epithelia, 
while the duct of the gland contains columnar epithelia. The 
cuboidal epithelia are always twice as large as the pus- corpuscles 
and larger than those from the convoluted tubules of the kidney. 
They have the same size as the cuboidal epithelia from the ureters, 
and when they are present alone, without the columnar epithelia 
from the duct, the comparative number of these, with those of 
the kidney and pelvis of the kidney, must be taken into considera- 
tion. An inflammation of the ureters is almost invariably sec- 
ondary to a nephritis or pyelitis, and when the epithelia from the 
kidney or pelvis, or both, are seen, together with'a small number 
of those twice the size of the pus- corpuscles, they are always 
ureteral. The absence of symptoms of a pyelo- nephritis, but the 
presence of a varying number of cuboidal epithelia double the 
size of pus -corpuscles, would show that they are from the pros- 
tate gland. Since a prostatitis, especially when it has lasted for 
some time, may cause a secondary inflammation of the bladder, 
the ureters, pelvis of the kidney and kidney, epithelia from 
all these organs may be present, and here not only the compara- 
tive number, but also the clinical symptoms of the case, will 
have to be taken into consideration to determine the positive 
source of the epithelia. 

On the other hand, in an inflammation of the prostate gland, 
the columnar epithelia from the duct of the gland are almost 
invariably present with the cuboidal epithelia in moderate or 
even large numbers, while the columnar epithelia from the 
ureters are rarely seen, and then in small numbers only. The 
columnar epithelia from the pelvis of the kidney, although 
they vary in size to a certain degree, are always somewhat 
larger than those from the duct of the prostate gland and 
more irregular, so they cannot be mistaken for the latter. 

A prostatitis is in most cases associated with inflammation 
either of the urethra or of the bladder (especially the neck), or 
both, and the epithelia from these organs will then be asso- 
ciated with those from the prostate gland. Severe cases, will, 
as already mentioned, be ascending in character, producing a 
pyelitis and finally a nephritis, with all the accompanying 
features of the same. 







i^#©^##@y^RB 



Fig. 104. Acute Abscess of the Prostate Gland (X 500). 

RB, red blood-corpuscles; PC, pus-corpuscles; PE, epithelia from the prostate gland; 

DP, epithelia from the duct of the prostate gland ; UE, epithelia from the urethra ; 

CT, connective-tissue shreds ; MS, mucus-threads ; MB, epithelia from the middle layers 
of the bladder. 



(235) 



236 URINARY ANALYSIS AND DIAGNOSIS 

Acute suppurative prostatitis, or abscess of the prostate 
gland, is of common occurrence, and its features are illustrated 
in Fig. 104. 

We see here red blood -corpuscles in moderate numbers, and 
pus -corpuscles in extremely large amount, which not infre- 
quently fill up entire fields of the microscope. Cuboidal epi- 
thelia from the prostate gland, as well as columnar epithelia 
from the duct, are always present in these cases, and are not 
infrequently found in groups. Connective -tissue shreds are 
seen in varying numbers, and unless they are found, the diag- 
nosis of an abscess must never be made, even if pus -corpuscles 
and epithelia are numerous. The latter is the chief point of 
distinction between a severe, but non- suppurative, prostatitis 
and an acute abscess. Mucus -threads may be found in large 
numbers. 

When a suppurative prostatitis is the result of a urethritis, 
which is frequently the case, the irregular epithelia from the 
urethra will be found accompanying the features just described, 
and, as a rule, epithelia from the upper and middle layers of 
the bladder are also present, showing a cystitis. In both the 
urethral epithelia and the bladder epithelia an endogenous new- 
formation of pus -corpuscles may be seen. 

Chronic Prostatitis. — Chronic prostatitis will give charac- 
teristic features under the microscope (Fig. 105). 

Red blood -corpuscles are here either entirely absent or 
scanty, and pus -corpuscles are present in moderate numbers 
only. Cuboidal as well as columnar epithelia from the pros- 
tate gland and its duct are quite abundant, the former being 
often found in groups of four, five, or more. Both the pus- 
corpuscles and the epithelia are studded with glistening fat- 
globules and -granules, which latter also lie free. In the case 
from which the illustration was drawn, this fatty change was ex- 
tremely pronounced — more so than is usually the case. Every 
epithelium and almost every pus -corpuscle was filled with these 
globules, giving the whole corpuscle a glistening appearance. 
The free groups of fat- globules were numerous and large, the 
individual globules in many groups being of considerable size. 
Mucus -threads were seen in moderate numbers, but connective- 
tissue shreds were absent. 

In this case no urethral epithelia were seen, but the accom- 
panying cystitis was pronounced, so that the epithelia from the 




Fig. 105. Chronic Prostatitis (X 500). 

PC, pus-corpuscles, containing fat-globules ; PE, epithelia from the prostate gland, con- 
taining fat-globules ; DP, epithelia from the duct of the prostate gland, containing fat- 
globules ; MB, epithelia from the middle layers of the bladder ; NB, epithelia from the neck 
of the bladder; MR, mucus-threads; FG, free fat-globules. 



(237) 



238 URINARY ANALYSIS AND DIAGNOSIS 

bladder were quite abundant. Not only the regular cuboidal 
epithelia from the middle layers of the bladder, studded with 
fat -globules, were present, but also larger epithelia from the 
neck of the bladder. Mention should here be made of the 
fact that the epithelia from the neck of the bladder are usu- 
ally larger than those found in the other portions of the bladder, 
and may even attain the size of vaginal epithelia. These large 
epithelia are, however, never numerous, are seen onlj- with the 
other features, and are not studded with bacteria, as is almost 
invariably the case in the epithelia from the upper layers of the 
vagina. 

Hypertrophy of the prostate gland may give characteristic 
features in the urine, even before the clinical symptoms are 
sufficiently pronounced to lead to a suspicion of the affec- 
tion. In these cases all the features of a chronic prostatitis 
are found, usually with a small or moderate number of pus- 
corpuscles only, but with small connective -tissue shreds, which 
in many cases are scanty. If the latter are seen with all the 
evidences of a chronic prostatitis, especially when the age of the 
patient is above forty or forty -five years, the diagnosis of hyper- 
trophy can be made. When the hypertrophy becomes more pro- 
nounced, the endogenous new -formation will be seen in the 
larger numbers of epithelia from the middle layers of the 
bladder. In 'these cases, prostatic concretions, previously 
described, are not rarely found. 

Tuberculosis. — Tuberculosis of the prostate gland is probably 
never present alone without an involvement of the neighboring 
organs, and is a comparatively rare affection. It will always give 
the symptoms of a prostatitis or an abscess of the prostate gland 
with a considerably impaired constitution, as shown by the pale, 
finely granular pus-corpuscles. When it is suspected, repeated 
examinations for tubercle bacilli must be made. 

Tumors — Tumors of the prostate gland are also of rare 
occurrence, but both sarcoma and cancer are met with, and can 
be diagnosed from the urine. In sarcoma, the characteristic 
small, glistening bodies previously described, with large connec- 
tive-tissue shreds, and the evidences of a chronic prostatitis are 
seen; while in cancer the connective -tissue shreds and epithelia, 
described in cancer of the bladder, may be found in the urine. 
The clinical symptoms must of necessity help the microscopical | 
examination in many of these cases. 



DISEASES OF THE SEXUAL ORGANS 239 

SPERMATORRHOEA 

Spermatorrhoea, which in young men is by no means rare, and 
consists in an occasional involuntary flow of semen, especially at 
the end of defecation, or even upon urination, can not infre- 
quently be diagnosed from the urine. 

When a urine is to be examined to prove the presence of a 
spermatorrhoea, it is best to take either the first urine voided in 
the morning, or the last quantity voided during defecation. In 
such a urine the elements of the sperma, with spermatozoa in 
large numbers, will be found. In almost all these cases a pros- 
tatitis of varying degrees of intensity will exist and give the 
features under the microscope. 

Whenever a prostatitis is found in young men in whom no 
other cause can be discovered, a suspicion of spermatorrhoea must 
arise, even when no spermatozoa are seen in the urine first 
examined. Repeated examinations will invariably show these, 
and render the diagnosis positive. The clinical symptoms of a 
chronic prostatitis — that is, an occasional discharge of a clear, 
viscid fluid, especially in younger men, — may not infrequently 
lead to the mistaken diagnosis of spermatorrhoea, which disease 
must never be diagnosed without the evidence of a discharge 
of sperma. 

Besides the prostatic epithelia, those from the ejaculatory ducts 
may also be seen in the urine. Mucus is always present in these 
cases in large amount, and mucus -casts or cylindroids may be 
abundant. Care must be taken not to mistake these for regular 
hyaline casts from the uriniferous tubules of the kidney, which 
they sometimes resemble to a marked degree ; sharp focusing will 
always bring out the pale fibers of mucus, thus proving that they 
are not hyaline casts. 

SEMINAL VESICULITIS 

Seminal vesiculitis or spermatocystitis has received considerable 
attention of late years by many authors, who all agree that the 
affection is of much more common occurrence than has been sup- 
posed. Although frequently of gonorrhceal origin, this is not 
the exclusive cause of the disease, and Fuller claims that in 
about one -third of the cases it is tubercular in character. It may 
also be catarrhal in origin, though most authors believe that the 
non - gonorrhceal cases are rare. 



240 UEIXAEY AXALYSIS AXD DIAGNOSIS 

Clinical Symptoms. — The symptoms of a spermatocystitis are 
not always well pronounced, and, therefore, may escape detection 
for years. Disturbances of the sexual functions are most con- 
stant, though they vary in different cases. In many there is a 
marked increase of sexual desire, but no relief is afforded by the 
coitus. This is, however, not present in every case, and in some 
there is a diminution or even absence of the desire. Pain may be 
present in the perina?um and upon urination, and there may even 
be tenesmus. In many cases an intermittent or even constant 
discharge from the urethra, which is sometimes quite profuse, is 
present, and some patients will complain of bloody emissions. 

It will be seen that neither one of these symptoms is at all 
characteristic, and rectal examination must be resorted to. This 
is sometimes successful, but in many cases is not ; when the 
seminal vesicles can be reached, they will be found distended 
and tender to the touch. A positive diagnosis can only be 
reached by a microscopical examination, and the seminal fluid 
will, in all these cases, contain pus -corpuscles, and usually, 
especially in acute cases, red blood- corpuscles. 

Features Found in Trine. — The microscopical examination of 
the urine will often clear up the case, provided seminal fluid is 
found in it. The early morning urine, especially the part first 
voided, or the last urine passed at defecation is best for this 
purpose. The features found in seminal vesiculitis are illustra- 
ted in Fig. 106. 

Spermatozoa are here found in large numbers. Some of them 
have the normal appearance, but the larger number are changed. 
The change takes place in the head of the spermatozoon, which 
becomes larger, round, and granular, and finally has the appear- 
ance of a pus -corpuscle, so that we seem to see pus -corpuscles 
with tails in such a urine. This change is characteristic 
of the disease, and is invariably seen, though not always as 
pronounced as here shown. The originally oval head first be- 
comes rounded and then somewhat enlarged and granular. In 
milder cases a further enlargement will take place in a few 
spermatozoa only, while in the more pronounced cases many 
assume the size of pus -corpuscles, being either coarsely or finely 
granular. 

Besides the spermatozoa, pus -corpuscles are always found in 
such a urine, and may be either scanty or numerous, according to 
the degree of inflammation. Since suppuration not infrequently 




Fig. 106. Spermatocystitis or Seminal Vesiculitis (X 500). 

PC, pus-corpuscles ; RB, red blood-corpuscles ; S, spermatozoa ; SP, spermatozoa, heads 
appearing like pus-corpuscles ; EE, epithelia from the ejaculatory duct; PE, epithelia from the 
prostate gland ; DP, epithelia from the duet of the prostate gland ; MC, mucus-casts ; 
FG, free fat-globules. 



(241) 



242 URINARY ANALYSIS AND DIAGNOSIS 

occurs in the seminal vesicle, pus -corpuscles may be very numer- 
ous. Red blood- corpuscles are almost always present, though 
their number also varies considerably, being abundant in the 
more pronounced and scanty in the milder or the chronic cases. 

Epithelia from the ejaculatory duct can always be found. 
These are originally columnar ciliated epithelia, and in some the 
cilia will be seen, while in others they are broken off. . When 
they are broken, delicate parallel rods in the interior of the epi- 
thelia, near their basal surfaces, may indicate that the epithelia 
were originally ciliated. 

In all cases examined, epithelia from the prostate gland were 
present, showing that the prostate gland was also inflamed. The 
numbers of prostatic epithelia will, however, vary considerably, 
though they are usually fairly abundant, both the cuboidal and 
columnar epithelia being seen. In the more chronic cases fat- 
globules are found, both in the epithelia and lying free. Mucus 
is always greatly increased in these cases, and cylindroids or 
mucus -casts may be numerous ; the mucus -threads sometimes 
assume large sizes. When suppuration exists, connective -tissue 
shreds are always present. Epithelia from the urethra and the 
bladder may accompany the other features. 

VAGINITIS 

Inflammations of the vagina, especially mild chronic cases, 
are of common occurrence, and have little significance, the only 
symptom being a slight discharge ; few women who have borne 
children are entirely free from this affection. The severer cases 
may be due to many causes, such as exposure to cold, gonorrhoeal 
infection, or injuries of any kind, or may be secondary to an 
inflammation of the uterus. 

Features Found in Urine. — It is rare that in the urine of a 
female vaginal epithelia are not found in greater or less amount. 
Epithelia from the upper layers are shed in a small amount in 
perfect health, and have no significance ; such epithelia may be 
seen even in small children. So long as the flat epithelia from 
the upper layers are present alone in small numbers, without 
cuboidal epithelia from the middle layers and without pus -cor- 
puscles, the diagnosis of a vaginitis can not be made. As soon, 
however, as large cuboidal epithelia are also' present, a patho- 
logical process of some kind exists in the vagina. 

Catarrhal Vaginitis. — The common forms of vaginitis seen 




Fig. 107. Chronic Catarrhal Vaginitis (X 500). 

PC, pus-corpuscles ; XIV, epithelia from the upper layers of the vagina ; MV, epithelia 
from the middle layers of the vagina, containing fat-globules ; BE, epithelia from the Bar- 
tholinian gland ; FG-, free fat-globules ; BC, bacilli and cocci. 



(243) 



244 URINARY ANALYSIS AND DIAGNOSIS 

in the urine are the mild chronic cases, and the features found 
are shown in Fig. 107. 

Pus -corpuscles are always present, but usually in small num- 
bers only. Epithelia from the upper and middle layers of the 
vagina are quite numerous. These epithelia are considerably 
larger than those from the bladder, the upper layers being flat, 
the middle cuboidal. Epithelia from the upper layers are fre- 
quently studded with bacilli and cocci, and often contain 
variously sized extraneous fat -globules. They may be found in 
groups, which may fill the greater part of the field. Cuboidal epi- 
thelia from the middle layers, which in urine usually appear round 
or oval, though they vary in size sometimes to a great degree, 
are always larger than those from the bladder, and may also 
be found in groups. Columnar epithelia from the deepest layer 
are not seen in these milder cases, but only in severe inflamma- 
tions or ulcerations. 

Besides these epithelia, small cuboidal epithelia, twice the 
size of pus -corpuscles and exactly similar to those from the 
prostate gland in the male, are usually present ; these are 
the epithelia from the Bartholinian gland and denote a slight 
Bartholinitis. 

Pus -corpuscles, as well as the different epithelia, contain 
small fat -globules in varying numbers in all chronic cases. 
Free fat -globules may also be seen. In most, if not in all 
cases of vaginitis, micro-organisms, both cocci and bacilli, are 
found, and are, as a rule, quite abundant. Their presence has 
no significance, as it is well known that micro-organisms always 
exist in the vagina, the more pronounced if an inflammation 
has developed. The characteristics here described are usually 
seen in urines examined for other reasons and containing 
other features. 

In acute vaginitis red blood -corpuscles as well as pus -cor- 
puscles will be abundant, and vaginal epithelia from the differ- 
ent layers quite numerous. In plain catarrhal vaginitis the flat 
and cuboidal epithelia are usually present alone, while in vagi- 
nitis due to gonorrhoea, and especially in ulcerative vaginitis, 
columnar epithelia from the deepest layer are also found, and 
connective -tissue shreds are present in varying amount. Epi- 
thelia from the Bartholinian gland are rarely absent, and when 
a suppurative inflammation sets in, as is often the case in 
gonorrhceal infection, are very abundant. 




Fig. 108. Traumatic Vaginitis (X 500). 

RB, red blood-corpuscles ; PC, pus-corpuscles ; UV, epithelia from the upper layers of 
the vagina ; MV, epithelia from the middle layers of the vagina ; DV, epithelia from the 
deepest layer of the vagina ; ES, epidermal scales ; BE, epithelia from the Bartholinian 
gland; CT, connective-tissue shred; BC, bacilli and cocci. 



(245) 



246 URINARY ANALYSIS AND DIAGONSIS 

Traumatic Vaginitis. — Traumatic vaginitis can also be diag- 
nosed from the urine. The features found in traumatic vaginitis, 
due to masturbation, are shown in Fig. 108. 

Pus -corpuscles are present in small numbers only, and red 
blood- corpuscles are not numerous ; but epithelia from all the 
layers of the vagina are abundant, the cuboidal from the middle 
layers and the columnar from the deepest layer being well marked. 
Epithelia from the Bartholinian gland are also seen in moderate 
numbers. Epidermal scales, showing corrugated edges, studded 
with fat -globules and dirt -particles, and not granular, are seen in 
every field. Connective -tissue shreds are also seen, though they 
are not numerous. Micro-organisms and a few fat -globules com- 
plete the features. 

Whenever epithelia from the deepest layer and connective- 
tissue shreds are present, we have all the evidences of a destruc- 
tive process. Continuous irritation or injury to the parts by 
masturbation is sufficient to produce these features in small 
numbers. If an ulcer exists, the pus -corpuscles and epithelia are 
more numerous, and if traumatism results in haemorrhage, red 
blood- corpuscles will be more abundant. The features here 
described may be found accidentally when a urine is examined for 
other pathological conditions, and when seen in that of young 
girls should always lead to a suspicion of masturbation. 

CERVICITIS AXD ENDOMETRITIS 

Cervicitis and endometritis may also be diagnosed from the 
urine, when the different epithelia from the cervix and mucosa of 
the uterus are present. Epithelia from the cervix uteri are quite 
large and irregular, while those from the mucosa uteri are co- 
lumnar ciliated. Both are shown in Fig. 101. The other features 
of such an inflammation are the same. In ulcerations or 
injuries shreds of connective-tissue are seen. In endometritis we 
occasionally find pus -corpuscles with cilia from the mucosa uteri. 
together with the ciliated epithelia. 

Tumors from the uterus can be diagnosed from examination 
of the urine in rare cases only, when a small particle of the 
tumor is cast off and found in the urine. The features of the 
tumor will be the same as previously described, and the epithelia 
will determine the seat of the tumor. 



INDEX 



Abscess of kidney, 187. 

Abscess of pelvis of kidney, 191. 

Abscess of prostate gland, 236. 

Acetic acid test for albumin, 18. 

Acetone, 30. 

Acid sediments, 42. 

Actinomj'ces, 133. 

Acute catarrhal cystitis, 212. 

Acute catarrhal nephritis, 165. 

Acute croupous nephritis, 174. 

Acute croupous haeniorrhagic nephritis, 

178. 
Acute croupous recurrences, 185. 
Acute prostatitis, 233. 
Acute suppurative prostatitis, 236. 
Acute ulcerative cystitis, 217. 
Acute urethritis, 231. 
Acute vaginitis, 244. 
Air-bubbles, 145. 
Albumin, 17. 
Albuminometer, 20. 
Albuminous substances, 17. 
Albuminuria, functional, 18. 
Albumose, 21. 

Alkaline change of acid urine, 61. 
Alkaline phosphates, 16. 
Alkaline sediments, 42, 57. 
Ammonio-magnesian phosphates, 57. 
Amoeboid changes of pus-corpuscles, 74. 
Amorphous simple phosphates, 59. 
Amount of solids, 8. 
Amount of urine, normal, 7. 
Amount of urine, pathological, 9. 
Amyloid corpuscles of prostate gland, 87. 
Amyloid degeneration of kidney, 158, 183. 
Amyloid disease of kidney, 183. 
Anatomical structure of kidney, 156. 
Aniline color, 126. 
Aniline water, 130. 
Animal parasites, 134. 
Anomalies of secretion, 194. 
Antiseptic substances, use of, 39. 
Appearance of urine in cystitis, 211. 
Ascaris lumbricoides, 138. 
Aspergilli, 122. 
Atrophy of kidney, 184. 



Bacillus subtilis, 125. 

Bacillus ureas, 125. 

Bacteria, development of in urine, i 

Bacterial casts, 119. 

Bacterium coli commune, 132. 

Bacterium termo, 125. 

Bacterium ureae, 125. 

Bacteriuria, 121. 

Bartholinian gland epitbelia, 93. 

Basidia, 122. 

Bilharzia haamatobia, 136. 

Bile pigments, 31. 

Bilirubin, 67. 

Bladder, diseases of, 209. 

Bladder epithelia, 81. 

Bladder, inflammations of, 209. 

Bladder, parasites in, 230. 

Bladder, tumors of, 223. 

Blood-casts, 110. 

Blood-clots, 72. 

Blood-corpuscles, 70. 

Bottger's test for sugar, 25. 

Brick-dust sediment, 44. 

Bright's disease, 155. 

Calcium oxalate, 49. 

Calculi, 68. 

Cancer of bladder, 227. 

Cancer of kidney, 208. 

Carbolic acid fuchsine solution, 131. 

Carbonate of lime, 62. 

Carbonate of lime concretions, 68. 

Casts. See also Tubular casts. 

Casts, bacterial, 119. 

Casts, cholestearin, 120. 

Casts, fat, 120. 

Casts, fibrin, 120. 

Casts from seminal vesicles, 117. 

Casts, haemoglobin, 120. 

Casts, pigment, 120. 

Casts, pseudo, 117. 

Casts, pus, 120. 

Casts, urate, 117. 

Catarrhal cystitis, 212. 

Catarrhal cystitis, acute, 212. 

Catarrhal cystitis, chronic, 214. 



(247) 



248 



INDEX 



Catarrhal nephritis, 162. 

Catarrhal nephritis, acute, 165. 

Catarrhal nephritis, chronic, 166. 

Catarrhal pyelitis, 172. 

Catarrhal vaginitis, 242. 

Causes of anomalies of secretion, 194. 

Causes of catarrhal nephritis, 163. 

Causes of chyluria, 202. 

Causes of croupous nephritis, 172. 

Causes of cystitis, 209. 

Causes of haenioglobmuria, 199. 

Causes of irritation of kidney, 162. 

Causes of prostatitis, 232. 

Causes of pyo-nephrosis, 187. 

Cellulose, 144. 

Centrifuge, use of, 38. 

Cercomonas urinarius, 139. 

Cervical epithelia, 94. 

Cervicitis, 246. 

Changes in urine upon standing, 8. 

Chemical examination, 7. 

Chemical sediments, 42. 

Chloride of sodium, 8. 

Chlorides, 15. 

Cholestearin, 65. 

Cholestearin casts, 120. 

Chromic acid for preservation of sedi- 
ment, 39. 

Chronic catarrhal cystitis, 214. 

Chronic catarrhal nephritis, 166. 

Chronic croupous nephritis, 180. 

Chronic prostatitis, 236. 

Chronic ulcerative cystitis, 219. 

Chronic urethritis, 231. 

Chronic vaginitis, 244. 

Chyluria, 33, 64, 202. 

Ciliated epithelia from ejaculatory duct, 88. 

Ciliated epithelia from mucosa uteri, 94. 

Ciliated pus-corpuscles, 75. 

Cirrhosis of kidney, 170. 

Classification of nephritis, 155. 

Clay water sediment, 47. 

Cleanliness, 2. 

Clinical symptoms of anomalies of secre- 
tion, 194. 

Clinical symptoms of catarrhal nephri- 
tis, 163. [173. 

Clinical symptoms of croupous nephritis, 

Clinical symptoms of cystitis, 211. 

Clinical symptoms of prostatitis, 233. 

Clinical symptoms of pyo-nephrosis, 188. 

Clinical symptoms of spermatocystitis, 
240. 

Clinical symptoms of tumors of bladder, 
223. 



Clinical symptoms of tumors of kidney, 
205. 

Coefficient of Haeser, 10. 

Colloid corpuscles of prostate gland, 87. 

Color of urine, normal, 7. 

Color of urine, pathological, 9. 

Coloring matters of urine, 8, 31. 

Coloring of specimens, 126. 

Columnar epithelia, 78. 

Comparative sizes of pus-corpuscles and 
epithelia, 85. 

Concretions, 68. 

Congestion of kidney, 158. 

Conidia, 122. 

Connective tissue, 99. 

Connective tissue in atrophy of kidney,104. 

Connective tissue in cirrhosis of kidney, 
104. 

Connective tissue in haemorrhage, 101. 

Connective tissue in hypertrophy of pros- 
tate gland, 103. 

Connective tissue in intense inflamma- 
tion, 104. 

Connective tissue in suppuration, 101. 

Connective tissue in traumata, 101. 

Connective tissue in tumors, 102. 

Connective tissue in ulceration, 100. 

Consistency, normal, of urine, 8. 

Constituents of normal urine, 8, 12. 

Constitution, 75. 

Convoluted tubules, epithelia from, 84. 

Cork, 144. 

Corn-starch, 143. 

Cotton-fibers, 140. 

Creatinine, 8, 52. 

Croupous nephritis, 172. 

Crystalline sediments, 42. 

Cuboidal epithelia, 78. 

Cylindrical epithelia, 78. 

Cylindroids, 96. 

Cystine, 52. 

Cystine concretions, 68. 

Cystitis, 209. 

Cystitis, catarrhal, 212. 

Cystitis, suppurative, 219. 

Cystitis, ulcerative, 217. 

Decolorizing of specimens, 131. 
Detection of albumin, 18. 
Detection of sugar, 23. 
Dextrose, 23. 
Diabetis mellitus, 23. 
Diacetic acid, 30. 
Diseases of bladder, 209. 
Diseases of kidney and pelvis, 155. 



INDEX 



249 



Diseases of sexual organs, 231. 
Distoma haematobium, 136. 
Dorernus' ureometer, 14. 

Earthy phosphates, 16. 

Echinococci, 135. 

Eiuhorn's fermentation saccharometer, 28. 

Ejaculatory duct epithelia, 88. [82. 

Endogenous new-formations in epithelia, 

Endometritis, 246. 

Entozoa, 134. 

Epidermal scales, 80. 

Epithelia, 78. 

Epithelia, changes of, in urine, 79. 

Epithelia, columnar, 78. 

Epithelia common to both sexes, 81. 

Epithelia, cuboidal, 78. 

Epithelia, cylindrical, 78. 

Epithelia, flat, 78. 

Epithelia from Bartholinian gland, 93. 

Epithelia from bladder, 81. 

Epithelia from cervix uteri, 94. 

Epithelia froru. convoluted tubules of kid- 
ney, 84. 

Epithelia from ejaculatory ducts, 88. 

Epithelia from mucosa uteri, 94. 

Epithelia from pelvis of kidney, 83. 

Epithelia from prostate gland, 86. 

Epithelia from straight collecting tubules 
of kidney, 85. 

Epithelia from ureters, 84. 

Epithelia from urethra, 86. 

Epithelia from urine of female, 91. 

Epithelia from urine of male, 86. 

Epithelia from uriniferous tubules, 84. 

Epithelia from vagina, 91. 

Epithelia, horny, 80. 

Epithelia in normal urine, 78. 

Epithelia, simple, 79. 

Epithelia, sizes of, 79. 

Epithelia, squamous, 78. 

Epithelia, stratified, 78. 

Epithelial casts, 110. 

Esbach's albuminometer, 20. 

Extraneous matters, 140. 

Exudate, nature of in inflammation, 157. 

Faeces, 146. 
False casts, 117. 
Fat, 64. 
Fat-casts, 120. 
Fat-globules, 64. 
Fat-granules in epithelia, 83. 
Fat-granules in pus-corpuscles, 75. 
Fatty casts, 113. 



Fatty degeneration of kidney, 158, 180. 

Fatty matters, 33. 

Feather, 142. 

Features found in urine of catarrhal 

nephritis, 164. 
Features found in urine of croupous 

nephritis, 173. 
Features found in iirine of chyluria, 202. 
Features found in urine of haenioglobi- 

nuria, 200. 
Features found in urine of prostatitis, 233. 
Features found in urine of pyo-nephrosis, 

191. 
Features found in urine of renal tuber- 
culosis, 193. 
Features found in urine of sarcoma, of 

kidney, 205. 
Features found in urine of spermatocys- 

titis, 240. 
Features found in urine of vaginitis, 

242. 
Fehling's solution, 24, 26. 
Fermentation saccharometer, 28. 
Fermentation tests for sugar, 26, 28. 
Ferrocyanide test for albumin, 19. 
Fibrin, 22, 72. 
Fibrin-casts, 120. 
Filaria sanguinis hominis, 138. 
Fission-fungi, 124. 
Flat epithelia, 78. 
Flaws in glass, 145. 
Fuchsine, alcoholic solution, 126. 
Fuchsine, aniline water solution, 130. 
Fuchsine, carbolic acid solution, 131. 
Fuchsine, watery solution, 126. 
Functional albuminuria, 18. 

Gaseous constituents of urine, 8. 

Gentian violet solution, 128. 

Ghosts, 71. 

Gleet-threads, 89. 

Globulin, 21. 

Glomerulitis, 158. 

Glomerulo-nephritis, 158. 

Glucose, 23. 

Glycosuria, 23. 

Gmelins' test for bile pigments, 31. 

Gonococci, 126. 

Gonorrhoea, acute, 127. 

Gonorrhoea, chronic, 129. 

Gram's solution, 128. 

Granular casts, 112. 

Granulation of pus-corpuscles, 75. 

Grape sugar, 23. 

Gravel, 68. 



250 



INDEX 



Haematoblasts, 71. 

Haematoidin, 65. 

Haematoidin crystals in pus-corpuscles, 

75. 
Hematuria, 31, 73. 
Haemoglobin, 31. 
Haemoglobin casts, 120. 
Hemoglobinuria, 31, 199. 
Haemorrhage, 101. 

Haemorrhage from pelvis of kidney, 196. 
Haines' test for sugar, 25. 
Hay bacillus, 125. 
Heller's test for albumin, 19. 
Heller's test for haemoglobin, 32. 
Hemp-seed calculi, 68. 
Hippuric acid, 8, 53. 
Human hairs, 142. 
Hyaline casts, 108. 
Hydropic pus-corpuscles, 74. 
Hyperaemia of kidney, 158. 
Hypertrophy of prostate gland, 238. 
Hyphae. 122. 
Hyphomycetae, 121. 

Indican, 32. 
Indigo, 67. 

Indigo concretions, 68. 
Inflammations of bladder, 209. 
Inflammations of kidney, 155. 
Inflammations of pelvis of kidney, 155. 
Inflammatory corpuscles, 158. 
Inorganic constituents, 8, 15. 
Interstitial nephritis, 162. 
Interstitial nephritis, acute, 165. 
Interstitial nephritis, chronic, 166. 
Introductory, 1. 
Irritation of kidney, 161. 

Jaffe's test for indican, 32. 
Jaksch's test for diacetic acid, 30. 

Kidney, abscess of, 187. 

Kidney, amyloid disease of, 183. 

Kidney, anatomical structure of, 156. 

Kidney, anomalies of secretion of, 194. 

Kidney, atrophy of, 184. 

Kidney, cancer of, 208. 

Kidney, catarrhal inflammation of, 162. 

Kidney, cirrhosis of, 170. 

Kidney, croupous inflammation of , 172. 

Kidney diseases, 155. 

Kidney epithelia, 84. 

Kidney, fatty degeneration of, 180. 

Kidney inflammations, 155. 

Kidney, interstitial inflammation of, 162. 



Kidney, malignant tumors of, 204. 

Kidney, parenchymatous inflammation of, 
172." 

Kidney, sarcoma of, 205. 

Kidney, suppurative inflammation of, 187. 

Kidney, tuberculosis of, 191. 

Kidney, waxy degeneration of, 183. 

Koch-Ehrlich-Weigert method of color- 
ing, 130. 

Lactic acid in urine, 8. 

Large white kidney, 161, 180. 

Legals' test for acetone, 30. 

Lenses, 40. 

Leptothrix threads, 125. 

Leucine, 55. 

Leucocytes, 71. 

Leucorrhoea, 91. 

Lieben's iodoform test for acetone, 30. 

Linen-fibers, 141. 

Lipuria, 33, 64. 

Lithaemia, 47, 194, 

Lycopodium, 143. 

Magnifying powers, 40. 

Malignant tumors of kidney, 204. 

Margaric acid, 64. 

Materia peccans, 48. 

Melanin, 68. 

Methylene blue solution, 126. 

Micrococci gonorrhoea, 127. 

Micrococcus ureae, 124. 

Micro-organisms, 121. 

Micro-organisms, non-pathogenic, 121. 

Micro-organisms, pathogenic, 126. 

Microscopical features in cancer of blad- 
der, 227. 

Microscopical features in catarrhal cysti- 
tis, 212. 

Microscopical features in sarcoma of 
bladder, 226. 

Microscopical features in ulcerative cys- 
titis, 217. 

Mixed casts, 116. 

Moore-Heller test for sugar, 23. 

Morbus Brightii, 155. 

Mould-fungi, 121. 

Mounting of sediment, 39. 

Mucin, 21. 

Mucus, 96. 

Mucus-casts, 96. 

Mucus-corpuscles, 96. 

Mucus -threads, 96. 

Mulberry calculi, 68. 

Murexide test for uric acid, 14. 



INDEX 



251 



Mycelia, 122. 

Mycosis leptotkricia cystidis, 126. 

Nitric acid test for albumin, 19. 
Normal constituents of urine, 12. 
Normal urine, 7. 
Nuclei in pus-corpuscles, 75. 

Odor of urine, 8. 

Oidium lactis, 121. 

Oil-globules, 115. 

Organic constituents, 8. 

Oxalate of lime, 49. 

Oxalate of lime concretions, 68. 

Oxalic acid, 8, 49. 

Oxaluria, 51, 199. 

Oxyuris vermicularis, 139. 

Papilloma of bladder, 223. 

Parasites, animal, 134. 

Parasites in bladder, 230. 

Parenchymatous nephritis, 172. 

Pathological changes in atrophy of kid- 
ney, 160. 

Pathological changes in catarrhal inflam- 
mations, 158. 

Pathological changes in cirrhosis of kid- 
ney, 159. 

Pathological changes in croupous inflam- 
mations, 159. 

Pathological changes in inflammations of 
kidney, 158. 

Pathological changes in interstitial in- 
flammation, 158. 

Pathological changes in parenchymatous 
inflammation, 159. 

Pathological changes in suppurative in- 
flammation, 161. 

Pathological urine, 9. 

Pelvic epithelia, 83. 

Penicillium glaucum, 122. 

Peptone, 21. 

Pericystitis, 221. 

Perirenal abscess, 189. 

Permanent microscopical specimens, 40. 

Phosphate of magnesium, 63. 

Phosphates, 16. 

Phosphates of lime, 59. 

Phosphates, simple. 59. 

Phosphates, triple, 57. 

Phosphatic concretions, 68. 

Phosphaturia, 60. 

Pigment casts, 120. 

Pigment granules in pus-corpuscles, 75. 

Preservation of sediment, 39. 



Prostate gland, hypertrophy of, 238. 
Prostate gland, inflammation of, 232. 
Prostate gland, tuberculosis of, 238. 
Prostate gland, tumors of, 238. 
Prostatic concretions, 87. 
Prostatic epithelia, 86. 
Prostatitis, 232. 
Pseudo casts, 117. 
Pus-casts, 120. 
Pus-corpuscles, 73. 
Pus-corpuscles, derivation of, 74. 
Pyelitis calculosa, 198. 
Pyelo-nephritis, 166. 
Pyo-nephrosis, 187. 
Pyuria, 74. 

Quantitative test for albumin, 20. 
Quantitative test for sugar, 26. 
Quantitative test for urea, 13. 
Quantity of urine, normal, 7. 
Quantity of urine, pathological, 9. 

Red blood-corpuscles, 70. 

Renal tuberculosis, 191. 

Results when urine is boiled, 18. 

Rice-starch, 143. 

Roberts' fermentation test for sugar, 26. 

Rosenbach's test for bile pigments, 31. 

Rust particles, 145. 

Saccharomycetae, 123. 

Salts, 42. 

Sarcinse, 125. 

Sarcoma of bladder, 226. 

Sarcoma of kidney, 205. 

Scales from moth, 142. 

Schizomycetse, 124. 

Schizomycetse, pathogenic, 126. 

Scratches in cover glass, 145. 

Sediment, brick-dust, 44. 

Sediment, clay water, 47. 

Sediment, normal, 37. 

Sediment, pathological, 38. 

Sediment, preservation of, 39. 

Sedimentum lateritium, 48. 

Selection of urine, 1. 

Seminal tubules, casts from, 117. 

Seminal vesiculitis, 239. 

Serum albumin, 17. 

Simple epithelial lining, 79. 

Silk-fibers, 141. 

Sketching of features, 41. 

Smegma, 93. 

Solids in urine, 8. 

Solids, determination of, 10. 



252 



INDEX 



Specific gravity, determination of, 10. 

Sperma, 88. 

Sperma crystals, 89. 

Spermatocystitis, 239. 

Spermatorrhoea, 239. 

Spermatozoa, 89. 

Spores, 122. 

Squamous epithelia, 78. 

Staphylococci pyogenes, 124, 130. 

Star-shaped simple phosphates, 60. 

Starch-globules, 142. 

Stellate simple phosphates, 60. 

Sterigmata, 122. [85. 

Straight collecting tubules, epithelia from, 

Stratified epithelia, 78. 

Streptococci pyogenes, 124, 130. 

Stricture of urethra, 232. 

Strongylus gigas, 139. 

Subacute catarrhal cystitis, 217. 

Subacute catarrhal nephritis, 169. 

Subacute croupous nephritis, 178. 

Subnitrate of bismuth test for sugar, 25. 

Sugar, tests for, 23. 

Sulphate of lime, 56. 

Sulphates, 15. 

Suppurative cystitis, 219. 

Suppurative nephritis, 187. 

Suppurative prostatitis, 236. 

Suppurative pyelitis, 191. 

Suppuration, 101. 

Surgical kidney, 187. 

Tests for acetone, 30. 

Tests for albumin, 18. 

Tests for albumose, 21. 

Tests for chlorides, 15. 

Tests for coloring matters, 31. 

Tests for diacetic acid, 30. 

Tests for fibrin, 22. 

Tests for globulin, 21. 

Tests for haemoglobulin, 32. 

Tests for indican, 32.' 

Tests for mucine, 22. 

Tests for organic constituents, 14. 

Tests for peptone, 21. 

Tests for phosphates, 16. 

Tests for sugar, 23. 

Tests for sulphates, 15. 

Tests for urea, 13. 

Tests for uric acid, 14. 

Tests for urobilin, 32. 

Traumata, 101. 

Traumatic vaginitis, 246. 

Trichomonas vaginalis, 134. 

Triple phosphates, 57. 



Trommer's test for sugar, 24. 
True casts, 106. 
Tubercle bacilli, 130. 
Tuberculosis of kidney, 191. 
Tuberculosis of prostate gland, 238. 
Tubular casts, 105. 
Tubular casts, blood, 110. 
Tubular casts, epithelial, 110. 
Tubular casts, fatty, 113. 
Tubular casts, granular, 112. 
Tubular casts, hyaline, 108. 
Tubular casts, mixed, 116. 
Tubular casts, waxy, 114. 
Tumors, 102. 
Tumors of bladder, 223. 
Tumors of kidney, 204. 
Tumors of prostate gland, 238. 
Tumors of uterus, 246. 
Typhoid bacilli, 132. 
Tyrosine, 55. 

Ulceration, 100. 

Ulceration in urethra, 232. 

Ulcerative cystitis, 217. 

Ultzman's test for bile pigments, 31. 

Urate casts, 117. 

Urate of ammonium, 60. 

Urate of ammonium in statu nascenti, 49, 

Urate of potassium, 48. 

Urate of sodium, amorphous, 47. 

Urate of sodium, crystalline, 48. 

Urate of sodium in transition, 49. 

Urea, 12. 

Urea, nitrate, 12. 

Urea, quantitative test for, 13. 

Ureometer, Doremus', 14. 

Uretral epithelia, 84. 

Urethral epithelia, 86. 

Urethral threads, 89. 

Urethritis, 231. 

Uric acid casts, 117. 

Uric acid, chemical test, 14. 

Uric acid, common form, 44. 

Uric acid concretions, 68. 

Uric acid diathesis, 46. 

Uric acid from over acid urine, 45. 

Uric acid gravel, 46. 

Uric acid under microscope, 43, 47. 

Urinary concretions, 68. 

Uriniferous tubules, epithelia from, 84. 

Urobilin, 8, 32. 

Uroerythrin, 8. 

Uroindican, 8, 32. 

Uroxanthin, 8. 

Uterine epithelia, 94. 



INDEX 253 

Vaginal epithelia, 91. Whitney's reagent, 27. 

Vaginitis, 242. Wool-fibers, 141. 

Vaginitis, catarrhal, 242. 

Vaginitis, traumatic, 246. Xanthin, 8. 

Vegetable matter, 146. Xanthin concretions, 68. 

Vesuvin solution, 128. 

Yeast-fungi, 123. 
Waxy casts, 114. 

Waxy degeneration of kidney, 158, 183. Ziehl-Neelsen's carbolic acid fuchsine 

Water-fungi, 149. solution, 131. 

Wheat-starch, 143. Zooglcea, 124. 
White blood-corpuscles, 71. 




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